
fihss fiC*\4r 

Book 4 2-5 

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COPYRIGHT DEPOSIT. 



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BLOOD PRESSURE 
SIMPLIFIED 



First Edition 



Published by Medical Department of 

Jaybr Instrument Companies 

Rochester, N. Y. 






Copyrighted 1917 

By 

Ityor Instrument Companies 

Rochester, N. Y. 






5fi i 



JUL -2 1917 



>Q.A467714 



Foreword 

^THERE has been a constant and in- 
sistent demand for a handy refer- 
ence book on Blood-Pressure. 

This book has been prepared to satisfy 
that demand. In its preparation, in 
addition to much valuable original 
matter, quotations from recognized 
authorities only, have been used. 

In the Bibliography, reference has been 
made to a wide variety of recognized 
authorities, covering in its entirety the 
subject matter of this book. 



Contents 

Chapter 1: 

The Physiology of Arterial Tension. 

Chapter 2: 

Hyper-tension. 

Chapter 3: 

Hypo-tension. 

Chapter 4: 

Diseases in Which Pressure is Not Definitely Known. 

Chapter 5: 

Therapeutics of Abnormal Blood Pressure. 

Chapter 6: 

Blood Pressure in Life Insurance and a Consideration 
of the Tests for Cardiac Efficiency. 

-Chapter 7: 

Blood Pressure in Ophthalmology. 

Chapter 8: 

Blood Pressure in Obstetrics and Surgery. 

Chapter 9: 

Heart Irregularities. 

Chapter 10: 

Types of Sphygmomanometers. 



CHAPTER I 

PHYSIOLOGY OF ARTERIAL TENSION 

Definition — The Heart — History — Mechanism of the 
Circulation — Three Factors of Blood Pressure — Relative 
Values of the Three Pressures — Accepted Methods of 
Determining Blood Pressure — General — Application of the 
Sleeve — Sound Phenomena — Causes of the Sounds — Esti- 
mation of Systolic Pressure — Estimation of Dias- 
tolic Pressure — Valuable Information to be Gained from 
Observation of Hand Movements — Palpatory Method of 
Estimating Blood Pressure — Oscillatory Method of Esti- 
mating Diastolic Pressure — Pulse Pressure — Mean Pres- 
sure — When to Take Blood Pressure- — Heart Load Ratio 
— Peripheral and Splanchnic Factors — Viscosity — Venous 
Pressure — Normal Blood Pressure — Infants and Children 
— Posture — Atmospheric Influences — Barometric Pressure. 

Definition — "Blood Pressure is the term used to 
indicate the pressure which the blood is exerting 
upon the walls of the vessel in which it is to be 
measured (lateral pressure) or upon the column 
of blood ahead of it in the direction in which it is 
flowing (end pressure)" — Hirschf elder. (1) 

The arteries are a set of elastic tubes and the 
pressure of the blood in any one segment is 
brought about by the tendency of the inflow from 
the heart to remain in excess of the outflow 
through the capillaries. 

THE HEART 

"Though the left ventricle, dispensing its load 
under a high pressure into the aorta, is the master 
hand in maintaining the arterial blood-pressure, 
the height to which that pressure rises depends 
primarily on the resistance encountered in the 



2 BLOOD PRESSURE SIMPLIFIED 

peripheral arterial system, and in the capillaries, 
and secondly on the response of the ventricle to 
overcome that resistance. Given a normal ven- 
tricle the arterial tonus largely determines the 
ventricular response, and the level of the arterial 
blood pressure — and this is the key-note of physio- 
logical and pathological variation of that pres- 
sure."^ — Oliver. (55) 

HISTORY 

The first blood-pressure determination of which 
we have definite record was made in 1855 by 
Vierordt when he ascertained the weight which 
would obliterate the pulse. His method, how- 
ever, was very crude and gave us very little infor- 
mation. Marey was probably the originator of 
the first useful apparatus for determining blood- 
pressure — which was by the plethysmograph. He 
also made the first observations on the relation 
of the arterial volume change to the shape of the 
artery when the systolic wave is received, and 
thus arrived at a very fair estimate of the minimal 
pressure. Unfortunately, his work was little 
known and it remained for V. Basch in 1887 to 
really introduce blood-pressure determinations 
into clinical work. His instrument consisted of a 
small rubber bulb filled with water and connect- 
ing with a mercurial manometer. The bulb was 
pressed upon the radial artery until the pulse was 
obliterated. Riva-Rocci and Barnard and Hill 
introduced the use of the rubber bag surrounded 
by the non-elastic cuff of leather. 

Though numerous methods for determining 
the minimal blood pressure had been devised, 



PHYSIOLOGY OF ARTERIAL TENSION 3 

notably those of Mosso, it remained for Masing 
in 1901 to suggest measuring the minimal 
pressure by the point at which the radial pulse 
became the largest. 

At about that time Janeway estimated the min- 
imal pressure at the point where the oscillation of 
the mercury column in the manometer became 
greatest. 

Shortly after, Erlanger (3) developed his Re- 
cording Sphygmomanometer and elaborated the 
oscillatory method of determining blood-pressure. 

The greatest advance, however, was in 1905, 
when the Russian, Korotkoff, brought out his 
auscultatory method. Since then blood-pressure 
technique has been considerably developed, 
largely through the simplicity and exactness of 
this method. Blood-pressure determinations of 
both maximal and minimal pressure are rapidly 
becoming a routine practice in the physical exam- 
ination of every patient. 

MECHANISM OF THE CIRCULATION 

The force by which the blood is driven from the 
heart into the ramifications of the arterial tree is 
derived almost entirely from the contraction of 
the left ventricle. The ventricle is doing effective 
work during only a part of the period of its con- 
traction, because the intraventricular pressure 
must not only equal, but must overcome the static 
column of blood in the aorta and the resistance of 
the aortic valve before the blood can be thrown 
into its channels. 

As shown by Huerthle and Porter (2) the pres- 
sure in the ventricle remains tolerably constant 



4 BLOOD PRESSURE SIMPLIFIED 

during the entire systole and a part of the energy 
is rendered potential in the arterial walls. 

However, the intraventricular pressure falls, if 
the peripheral resistance is very low and rises if 
high. In a given arterial system the pressure of 
the pulse wave is greatest in the aorta. 

The amount of diminution is determined by the 
friction due to the narrowing caliber and to the 
tone of the vessel walls in which it is flowing. 
Normally in the capillaries there is no pulsation, 
because the head of pressure in the arteries has 
been absorbed and the systolic prssure and dias- 
tolic pressure are almost equal (See Figs. 1 and 
2.) The amplitude of the pulse wave is not a func- 
tion of the pressure alone, but is also an indica- 
tion of the resiliency of the arterial wall. 

THREE FACTORS OF BLOOD PRESSURE 

Since the moving of the circulation is brought 
about by a series of pulsations, due to the heart's 
contraction, it is evident that in a set of elastic 
tubes, such as the arteries, the pressure fluctua- 
tions must be considerable. 

The highest and lowest points of these fluctua- 
tions are termed maximal and minimal pressures, 
corresponding to the contraction and rest intervals 
of the heart, respectively. The pressure generated 
by the ventricular contraction is a comparatively 
large force, acting over a short period of time 
(systole.) This energy is made potential in the 
arterial walls where it acts as a small amount of 
power over a comparatively long period of time. 
The difference between this high and low point of 



IASTOLIC PRESSURE 




DIRECTION OP RESISTANCE 



Diagram showing the left ventricle and arterial system 
during Diastole. The diastolic pressure is 80 mm. and 
represents a resistance borne by the aortic valves and 
arterial walls and directed contrary to cardiac force. The 
power furnished by the heart must be sufficient to equalize 
this resistance and enough in excess to render its work 
potential in the arterial wall. 




SYSTOLIC... .140 mm. 
DIASTOLIC ... 80 MM. 
PULSE 60 MM. 



SYSTOLIC 
DIASTOLIC 
PULSE . . . 



SYSTOLIC . . 
DIASTOLIC . 
PULSE 



SYSTOLIC . . 
DIASTOLIC ... 80 MM 
PULSE MM 



Schematic Representation of the Blood-Pres- 
sure in the Arteries. Particularly intended to 
show the changes produced during the passage of 
a single systolic wave toward the periphery. 

1 — Illustrates the volume of blood thrown into the 
aorta from the left ventricle under high pressure (60 mm. 
pulse pressure). 



2— Illustrates an absorption of pulse pressure from the 

nltl ,„ , i , , i,. instance. 

Pulse pressmAas been reduced by 10 mm. from previous 

!3^y^r^^ s «P^^-K 

reduced from 50 to 30 mm head of re has been 

almotrentirely aSed. systolic and diastohc pressures 
being practically equal. 



PHYSIOLOGY OF ARTERIAL TENSION 5 

pressure represents the head of pressure which 
forces the blood onward toward the periphery. It 
is called the pulse pressure. A comprehensive 
knowledge of the blood-pressure, therefore, calls 
for a determination of these three factors — Sys- 
tolic, Diastolic and Pulse Pressures. 

RELATIVE VALUES OF THE THREE 
PRESSURES 

(See Figs. 1 and 2.) 

Systolic Pressure — Since during diastole the 
aortic valves are closed, the pressure of the blood 
in the arteries during this period represents a 
force directed contrary to cardiac force, and a 
resistance (peripheral resistance) that must be 
overcome by the next ventricular contraction. To 
efficiently maintain the circulation, the left ven- 
tricular contraction must furnish sufficient power 
to equal the peripheral resistance, with enough in 
addition to open the aortic valves and render its 
power potential in the arterial walls — Systolic 
Pressure represents total heart energy. 

Diastolic Pressure — The diastolic pressure rep- 
resents the entire load of pressure borne by the 
whole arterial system during systole. It is a 
resistance directed contrary to cardiac force, 
which must be equalized and overcome by the 
work of the heart. The diastolic pressure is but 
little affected by the transitory influences which 
so markedly affect the systolic and pulse pressures. 
Even comparatively slight changes, unless depend- 
ent on alterations in the pulse rate, are of much 
significance, as indications of circulatory condi- 



6 BLOOD PRESSURE SIMPLIFIED 

tions (vaso-motor influences, and other causes of 
change in the peripheral resistance) . 

Pulse Pressure — The pulse pressure represents 
the efficient work of the heart and indicates the 
extent to which it overcomes the peripheral resist- 
ance. It is the excess of pressure, over and above 
that required to equalize the diastolic pressure, 
which opens the aortic valves, renders the work of 
the heart potential in the arterial walls, and forces 
the blood onward into the capillaries. 

ACCEPTED METHODS OF DETERMINING 
BLOOD -PRESSURE 

Three methods have come into general use for 
determining the maximal and minimal blood-pres- 
sure. These are : 

1 — Auscultatory — Korotkoff 
2 — Oscillatory 
3 — Palpatory 

The first of these is eminently superior to the 
other two, and is the one in general use. The 
oscillatory method is used very little in the United 
States, but is more in use on the continent of 
Europe. The auscultatory method gives readings 
of about 8 mm. greater than the palpatory method. 

A majority of the earlier statistics have been 
gained from the other methods and this should be 
taken into consideration in comparing two sets of 
statistics made at different periods of blood-pres- 
sure development. There are times, however, 
when the oscillatory and palpatory methods are of 
use and for this reason they will be described. 




Fig. 3 
Method of Auscultation 




Fig. 4 
Method of Palpation 



PHYSIOLOGY OF ARTERIAL TENSION 7 

GENERAL 

There are certain general conditions which 
apply to all methods and which, though simple, are 
of considerable importance. 

APPLICATION OF THE SLEEVE 

It is highly important that nothing should be 
done to excite the patient, or to render him in any 
way apprehensive. The manner of talking to the 
patient and of applying the sleeve should be calm, 
and matter-of-fact. The attitude on the part of the 
physician, together with a minimum effort on the 
part of the patient, prior to the determination, 
will eliminate errors due to emotion, exercise, etc. 

True blood-pressure readings are taken upon 
reducing the counter pressure in the arm band, 
from above the point where its pressure obliter- 
ates the lumen of the artery. To avoid subjecting 
the arm to excessive or unduly prolonged pres- 
sure, such as would occur were the inflation 
carried far beyond this point, the approximate 
readings of maximal and minimal pressures are 
roughly noted on inflating the sleeve and verified 
as the counter pressure is slowly reduced. 

That part of the sleeve containing the rubber 
bag is placed well on the inside of the bare left 
arm above the elbow and the remainder of the 
sleeve wrapped around, precisely as a bandage 
would be applied, the last few inches tucked under 
the preceding fold. (See Figs. 3 and 4.) The 
question often arises as to the advisability of al- 
ways having the patient bare the arm. Speaking 
generally we should advise it — in the interest of 



8 BLOOD PRESSURE SIMPLIFIED 

scientific accuracy and for the welfare of the pa- 
tient. However, occasions do occur where it is 
quite impossible to have the patient under ideal 
conditions, and in these cases, where the sleeve 
must be applied over a heavy undergarment, al- 
lowances must be made for it, and where the 
pressure is near the border line proper technique 
should be insisted upon. 

For best results it is always necessary to have 
the patient under the same conditions as regards 
posture, time of day, meals, etc., in order that 
variations, due to physiological causes, may be 
eliminated. 

The manometer is attached to one of the tubes 
leading from the compression sleeve, the inflat- 
ing bulb, with release valve, is attached to the 
other tube. 

The stethoscope is used to determine the vari- 
ous pressure phases, as indicated by the difference 
in the sound during restoration of the interrupted 
blood column, obtained by reducing the counter 
pressure in the sleeve. 

Any of the many patterns of stethoscopes may 
be used. The one to which the physician has 
accustomed himself by use is usually to be pre- 
ferred. The only requirement is that the 
resonator be of a size sufficiently small that its 
entire circumference adapts itself snugly to the 
arm and shuts out all adventitious sounds. 

The resonator, or bell, should be placed over 
the brachial artery, well above the elbow and in 
the center of the space between the internal border 
of the biceps muscle and the internal condyle of 
the humerus. (See Fig. 3.) 



PHYSIOLOGY OF ARTERIAL TENSION 9 

SOUND PHENOMENA 

Between the upper and lower limits of sound 
production marked variations in character and 
intensity are recognizable, and these show consid- 
erable differences in various circulatory condi- 
tions. 

There are described five phases of sound during 
the lowering of the external pressure from above 
the obliteration point : 

Dial to Aid Memory. 

1 — A Clear Sharp Sound or Click — the Index of Sys- 
tolic Pressure. 

2 — A Murmur of Variable Duration replacing the 
above. 

3 — A Clear, Usually Loud and Snappy Sound, replac- 
ing the Murmur. 

4 — A Transformation (usually sudden, at other times 

more gradual) of the Clear, Loud Sound into 

a Dull One — The Index of Diastolic Pressure. 

5 — The Disappearance of all Sound. 

(See Fig. 5.) 

CAUSES OF THE SOUNDS: 

There has been considerable discussion as to the 
exact causes of the sounds heard through the 
stethoscope in the Korotkoff method. The best 
work done on this subject is probably that of 
Erlanger (3) and he sums up as follows: 

"The mechanism of sound production, in a word, 
is that the water-hammer moving through the 
artery in the compression chamber, under usual 
circumstances, strikes the stagnant blood in the 
uncompressed artery below and distends the 
artery there so as to give rise to sound. The wave 
started by this impact is transmitted down (and 



10 BLOOD PRESSURE SIMPLIFIED 

up?) the artery with sufficient amplitude to pro- 
duce sound locally as it proceeds, but only when 
the volume of blood coming through is sufficient 
and when the lower artery already is fairly full of 
blood, and therefore ordinarily only in the late 
second and third phases." 

ESTIMATION OF SYSTOLIC PRESSURE 

Criterion — The beginning of a clear, sharp tone 
on lowering the external pressure from above the 
obliteration point. 

1 — Place the stethoscope over the brachial 
artery about one half inch below the lower border 
of the sleeve (See Figs. 3 and 4.) No sound will 
be heard over the normal uncompressed artery. 

2 — On inflating the sleeve the sounds of the 
vibrating artery will be plainly heard, gradually 
growing fainter, as the external pressure is 
increased. Observe the point of disappearance of 
the sound and oscillations. It has occasionally 
been observed in individuals having hypertension 
that the second tone phase is often so faint as to 
be barely audible and the instance of the third 
phase may be mistaken for the systolic pressure. 
Therefore, as a precautionary measure, observe 
the point where hand oscillations and arterial pul- 
sations cease; this insures that the lumen of the 
artery is entirely obliterated. 

3 — Gradually lower the external pressure until 
a clear tone is heard. The point indicated by the 
hand on the dial, at the instant the sound is heard, 
marks the point of systolic pressure. 



*^i^ 




M/M 



Fig. 5 
Diagram to illustrate the characteristic change of tone and length of the various phases of 
sound heard through the stethoscope. 

1 — The first sound heard. A sharp click. The sign of systolic pressure. In the above diagram this phase 



2 — The second sound. A tone closely resembling a heart murmur. Has no 
tured here as lasting 20 mm. 

3 — The third sound. A click. Much like the first sound but generally loude 



particular signifies 

r and continues for about 5 mm. 

"iterion 



4 — The fourth sound. A dull thud or bump. The transition of the third to the fourth phase 
of diastolic pressure. Of variable duration; about 6 mm. 

IT IS OF COURSE UNDERSTOOD THAT THE LENGTH OF THE PHASES GIVEN ABOVE ARE 
TAKEN AS AN ILLUSTRATION ONLY AND SIMPLY REPRESENT A CONDITION FREQUENTLY FOUND 
IN THE NORMAL PERSON. THESE PHASE LENGTHS MAY CHANGE IN THE SAME INDI- 
VIDUAL ON REPEATED EXAMINATIONS. 



PHYSIOLOGY OF ARTERIAL TENSION 11 

ESTIMATION OF DIASTOLIC PRESSURE 

Criterion — the lowest point of the excursion of 
the hand on the dial, taken at the instant of tran- 
sition of sound from a clear loud tone to an appre- 
ciably dull tone. 

1 — The Systolic pressure having been observed, 
the external pressure is slowly and intermittently 
released a few millimeters (2 to 6 mm.) at a time, 
so that the nature of the hand movements and 
the character of the sounds may be accurately 
noted. 

2 — At the point where the third phase (phase 
of clear and loud tone production) is transformed 
into the fourth phase (an appreciably dull tone) 
the diastolic reading is taken at the lotvest point 
reached by the excursion of the hand on the dial. 

Though the method of Korotkoff has generally 
been considered an auscultatory method, it is 
really a combination of the oscillatory and auscul- 
tatory methods, because the true point of dias- 
tolic pressure is the lowest point of arterial pres- 
sure fluctuation. This is accurately indicated by 
the low point of the hand oscillation. 

VALUABLE INFORMATION TO BE GAINED 

FROM OBSERVATION OF HAND 

MOVEMEMENTS 

Valuable information may be derived concern- 
ing the general condition of the arterial system 
by noting the variations of amplitude, rate and 
rhythm of the pulse, as shown by the hand move- 
ments of the sphygmomanometer. 

Other things being equal, a small or a con- 
stricted artery, or an artery in which there has 



12 BLOOD PRESSURE SIMPLIFIED 

been considerable connective tissue change, usually 
gives a pulsation of small amplitude, while a large 
or a relaxed artery, or one of great resiliency will 
give an excursion of large amplitude. 

ALTERNATION OF THE PULSE 

Alternation of the pulse is a sign of grave prog- 
nostic import and indicates a badly damaged myo- 
cardium. According to Herrick (4) the sphyg- 
momanometer may be used to great advantage in 
diagnosing the condition. By raising the external 
pressure to a point where only half the beats come 
through, their alternation is easily discernible. 
(See Chapter 10). 

Auricular Fibrillation — The marked changes in 
the rhythm and amplitude of the pulse which 
occurs in this condition are clearly indicated by 
the movements of the needle. Methods of deter- 
mining blood-pressure under such conditions are 
considered under Chapter 10. 

PALPATORY METHOD OF ESTIMATING 
SYSTOLIC PRESSURE 

Criterion — The return of the pulse to the pal- 
pating fingers on lowering the external pressure 
from above the obliteration point. 

1 — Palpate the artery, care being taken that 
the pulse is not cut off by undue pressure. (See 
Fig. 4). 

2 — Inflate the sleeve, observing the amount of 
pressure required to totally extinguish the pulse. 
Advance the pressure about 20 mm. above this 
point. 



PHYSIOLOGY OF ARTERIAL TENSION 13 

3 — Gradually lower the external pressure until 
the pulse reappears. The point indicated by the 
hand on the dial, at the instant the pulse returns, 
marks the point of systolic pressure. 

OSCILLATORY METHOD OF ESTIMATING 
DIASTOLIC PRESSURE 

Criterion — the lowest reading of the oscillating 
hand taken at the point of abrupt diminution just 
after the greatest excursion of the hand on the 
dial. 

1 — The systolic pressure having been observed, 
slowly lower the external pressure a few milli- 
meters (2 to 6 mm.) at a time, so that the oscilla- 
tions of the hand may be carefully noted. 

2 — The lowest reading of the excursion of the 
hand taken at the point of abrupt diminution just 
AFTER the greatest oscillations have occurred 
marks the point of diastolic pressure. 

Note: The development of oscillation varies 
greatly and is influenced by so many factors that 
the method is not recommended. 

PULSE PRESSURE 

The pulse pressure is the difference between the 
systolic and diastolic pressures. For example: 

Systolic Pressure .... 120 mm. 
Diastolic Pressure .... 80 mm. 



Pulse Pressure 40 mm. 

MEAN PRESSURE 

Mean pressure is of little practical importance 
and is mentioned here simply for completeness. 
There are several ways of computing it, the most 
common being the method of dividing the sum of 
the systolic and diastolic pressures by two. 



14 BLOOD PRESSURE SIMPLIFIED 

Warfield (16) puts forth that the mean pres- 
sure follows the diastolic more closely than the 
systolic. 

Dawson (5) estimates the mean pressure 
by adding one third of the pulse pressure to the 
diastolic. 

WHEN TO TAKE BLOOD -PRESSURE 

Blood-pressure should be estimated in the first 
examination of every patient, in every examina- 
tion of the cardiovascular system, occasional 
examinations for the purpose of establishing 
progress in cardio-vascular-renal disease, and in 
every examination for the certification of health, 
as applications for life insurance, police, firemen 
and the examination of athletes. 

HEART LOAD RATIO 

Stone (6) has given a figure representing the 
heart load ratio in millimeters of mercury, obtain- 
ed by dividing the pulse pressure by the diastolic 
pressure thus: J1IL . According to him, the 
pressure necessary to equal diastolic pressure is 
of no use to the circulation, but the amount exerted 
in excess of this figure is the real measure of the 
circulatory efficiency. This he gives as 50%, as 
a normal heart load ratio; that is, a pulse pres- 
sure of one-half the diastolic pressure. For exam- 
ple: A diastolic pressure of 80 with a systolic 
pressure of 120 will give a pulse pressure of 40, 
obtained by subtracting the smaller from the 
greater pressure. The pulse pressure divided by 
the diastolic pressure has a fraction of one-half, 
or 50%.* 

* For further consideration of the above see under 
Diagnosis of Hyper-tension. 



PHYSIOLOGY OF ARTERIAL TENSION 15 

PERIPHERAL AND SPLANCHNIC FACTORS 

Richter (7) emphasizes the value of Poiseuille's 
Law, which is that the flow of blood is increased 
by the dilatation of a small artery at the ratio of 
the fourth power of the radius of a vessel, while 
pressure itself increases in arithmetical propor- 
tion. 

Turning now to the central area of the vascular 
system, we find the great splanchnic vessels of 
blood tanks of the abdomen, which are capable in 
themselves of containing practically the entire 
blood volume of the body. It is obvious that they 
must be in a state of considerable tonus all the 
time, in order to maintain the pressure in the 
arteries. 

A dilatation of these large receptacles, from 
whatever cause, constitutes one of the factors gen- 
erally found in shock. 

VISCOSITY 

"A word should perhaps be inserted here in 
regard to the viscosity of the blood. This property 
of the blood is very important in influencing the 
work of the heart, due to the friction co-efficient 
being largely dependent on this property. Vis- 
cosity of the blood depends almost entirely on the 
viscosity of the red corpuscles" — Hirschf elder (1) . 

It would seem also that the amount of oxygen 
carried by the blood has the effect of decreasing 
the viscosity. 

VENOUS PRESSURE 

Until quite recently it has been generally 
assumed that venous blood-pressure passively 



16 BLOOD PRESSURE SIMPLIFIED 

responds to changes in the peripheral resistance 
of the circulation and that it rises and falls in- 
versely to the pressure in the arteries. There is 
now a growing belief, supported in part by experi- 
ments on both animal and man, that the pressure 
in the venous system may be dominated by a 
special nervous mechanism. We cannot review 
the entire story of this chapter of the physiology 
of the circulation, which is still far from being 
presented in its final form. One apparent early ob- 
stacle to the hypothesis of a "venomotor" nervous 
mechanism has been in part met by the well estab- 
lished demonstration that the venous system is 
actually supplied with motor nerves. 

In distinction from the assumption that under 
normal conditions of life the peripheral resistance 
alone controls the magnitude of the venous pres- 
sure, Henderson (8) has put forth the hypothe- 
sis that there is a venopressor mechanism 
which functions to maintain an optimum feeding 
pressure to the heart. This forms a part of his 
theory respecting the maintenance of the volume 
output of the heart. The newest researches of 
Hooker (9) at Johns Hopkins Medical School on 
the venous blood-pressure in man, are in harmony 
with the existence of the hypothetic venomotor 
mechanism. 

According to Hooker (9), the venous pressure 
in man exhibits a distinct diurnal rhythm, rising 
throughout the day from 10 cm. to 20 cm. of water 
and falling again during the night. The normal 
venous pressure varies considerably, averaging in 
the day time and under usual conditions about 



PHYSIOLOGY OF ARTERIAL TENSION 17 

15 cm. of water ; in sleep, at night, it may fall to 
7 or 8 cm. 

NORMAL BLOOD -PRESSURE 

The normal systolic pressure in adults ranges 
from 105 to 145 mm. In children over two 
years of age from 85 to 110 mm. In females the 
pressure is about 10 mm. less than in males. 

The normal diastolic pressure ranges from 25 
to 50 mm. below the systolic pressure. 

A normal pulse pressure ranges from 25 to 
50 mm. 

A systolic pressure below 100, or above 150, and 
a pulse pressure below 25 or above 50 mm. may 
be regarded as abnormal. A diastolic pressure of 
105 or over is almost always pathological. 

INFANTS AND CHILDREN 

But very little work has been done on blood- 
pressure in infancy and childhood. It is difficult 
to make blood-pressure determinations on chil- 
dren, because of the emotional factors. Until 
recently no suitable apparatus has been on the 
market for these blood-pressure determinations in 
pediatric work. At the present time, however, 
there is a special form of sleeve available which 
is very satisfactory. In very young infants the 
arm is entirely too small for the ordinary cuff 
and it should be applied on the thigh. 

Melvin and Murrray (10) set a normal of sys- 
tolic 108 and diastolic 72, for the ages of 4 to 14 
inclusive. 

Before birth blood-pressure is higher in the pul- 
monic than in the systemic circulation. The 



18 BLOOD PRESSURE SIMPLIFIED 

expansion of the lungs which occurs in normal 
infants immediately after birth promptly lowers 
pulmonary blood-pressure. 

At birth systolic pressure is said to range be- 
tween 35 and 55 mm., waking and suckling causes 
a rise of about 15 mm. 

Preceding the onset of puberty there is a tend- 
ency toward a fall of pressure, during pubescence 
there is a period of increased pressure, which in 
turn is followed by a slight decrease after puberty 
has been established. 

POSTURE 

The question of the relation of posture to blood- 
pressure has received a great deal of attention 
recently, and as yet, after careful searching of 
literature, no definite statements may be made. 

It is contended by some (11) that blood-pressure 
is lower on the patient lying down, while others 
(12) say that it is the same and still others (13) 
say there is an increase in the systolic pressure 
and a decrease in the diastolic upon reclining, 
which would seem to be of considerable import- 
ance in this connection. However, the effort exer- 
cised by the individual in maintaining the given 
position — that is: whether the position is active 
or passive, is the important factor. In any case 
the posture should be the same in a series of read- 
ings, to insure correct results. 

Rolleston (12) mentioned a "Hypo-tension of 
Effort" existing in his convalescent cases, in 
which the pressure on standing was the same or 
slightly lower than in a recumbent position. 



PHYSIOLOGY OF ARTERIAL TENSION 19 

ATMOSPHERIC INFLUENCES 

Humidity — Recent research has shown that 
atmospheric humidity plays a tremendous part in 
physiological existence. This is nowhere more 
plainly shown than in its effect on blood-pressure. 
Comparatively slight increases in relative humid- 
ity, noticeably with a high dry-bulb temperature, 
causes very low systolic and diastolic readings. 

In a series of cases recently under our observa- 
tion, with a humidity of 80%, and a dry bulb tem- 
perature of 90° F. a number of systolic blood-pres- 
sures of 90 and 110 were found. Within 48 hours, 
with a subsequent drop in temperature and a low- 
ering of humidity, these pressures assumed the 
normal of near 120 and 130. The diastolic of 
these cases was also perceptibly lower. 

BAROMETRIC PRESSURES 

It has been averred by some investigators 
Dexter (14) that barometric pressure influ- 
ences our general lives to a marked extent, both 
physiologicaly and mentally, and no doubt the 
blood-pressure takes part in these responses to 
external conditions. 

The optimum of the vital functions of the 
human economy in all likelihood indicates some 
certain complex of other agencies, of which we are 
now only slightly cognizant; as for instance: the 
ultra-violet ray, light rays in general and radio 
active emanations, but our knowledge is so very 
slight that much research will be required before 
we can commit ourselves to positive statements. 



CHAPTER II 

HYPER- TENSION 

Definition — Transitory Rises Due to Physiological 
Causes — A Consideration of Hyper-tension in Relation to 
the Diseases in Which It Is a Factor. 

Definition. — Arterial hyper-tension is a term 
applied to the condition in which the tension of 
the blood in the arteries is above a certain point, 
closely associated with a normal functioning of 
the body. This normal point, or optimum of exist- 
ence, is subject to variations during the life of the 
individual, being higher at old age and lower in 
youth, but still representing a normal condition, 
if senility is admitted as normal. It is moreover 
probably true that each individual is largely a law 
unto himself and that several successive blood- 
pressure estimates are necessary to establish this 
point in a given case. 

TRANSITORY RISES DUE TO PHYSIOLOG- 
ICAL CAUSES 

It may be stated in the light of our present 
knowledge, that hyper-tension existing over a 
period of some duration (days) is abnormal and 
pathological. It follows therefrom that physio- 
logical rises are only transitory and the tendency 
to persist is a good criterion as to the normality 
of an existing hyper-tension. 

The functions of most organs are discontinuous 
and the blood supply to any organ depends on its 
state of activity. It follows from this that there 

20 



HYPER-TENSION 21 

are continual changes in the pressures in the 
arterial tree, to satisfy the calls of the various 
organs at different times. For instance: after 
meals there is a decided rise, due to the process of 
digestion, which is accompanied by dilated vessels 
in the stomach and accessory glands. Pressure 
must be raised to keep up the normal rate of flow 
of the blood that elimination, as well as nutrition, 
may be carried on properly. 

The EMOTIONAL STATES such as anger, 
fear, etc., cause a temporary hyper-tension. 

As was shown previously (Chapter 1) a reclin- 
ing posture, according to some authorities, raises 
blood-pressure. 

A dry, cold atmosphere may make a difference 
of 3 to 10 mm., blood-pressures being always 
higher in atmospheres of low humidity. 

Pressure is lowest during early morning hours 
when one is asleep. 

In women, menstruation causes a rise in blood- 
pressure just before the onset of the period. 

Defecation — Blood-pressure is raised during 
the process of defecation, due largely to the com- 
pression of the splanchnic blood vessels by the 
diaphragm and accessory abdominal muscles. 

A CONSIDERATION OF HYPER-TENSION 

IN RELATION TO THE DISEASES IN 

WHICH IT IS A FACTOR 

Heart Load Ratio: (See Stone's formula, Page 
14). 

On the basis of his heart load ratio figures, 
Stone classifies his hyper-tension cases into two 
groups — a Cerebral and a Cardiac group. 



22 BLOOD PRESSURE SIMPLIFIED 

The characteristics of the two groups are : 

First — In the Cerebral Group. We have a high 
diastolic pressure and a heart load ratio within 
normal limit. Under this group are found many- 
patients with high diastolic pressure and cerebral 
symptoms, the primary phases of which have for 
many years been placed under the heading of 
Uremia. 

Second — The Cardiac Group. The distinctive 
feature of this group is the low diastolic pressure 
as compared with the Cerebral group. In the 
Cardiac hyper-tension group the main subjective 
symptoms were fatigue on exertion and dyspnea, 
anginoid pains in chest, edema of extremities and 
palpitation. The death occurs most frequently 
with the symptoms of a gradually failing heart 
muscle. 

Arteriosclerosis — Arteriosclerosis may be de- 
fined as a chronic disease of the arteries and arter- 
iols, characterized anatomically by increase or 
decrease in the thickness in the walls of the blood 
vessels, the initial lesion being the weakening of 
the middle layer, caused by various toxic or 
mechanical agencies. This weakness immediately 
leads to secondary effects, which include the hyper- 
trophy or atrophy of the inner layer and not infre- 
quently hypertrophy of the outer layer — connect- 
ive tissue formation and calcification in the vessels 
and the formation of minute aneurysms along 
them. 

"Veins are sometimes affected in the general 
morbid process."— Warfield (16). 

Etiology — There is no doubt that heredity plays 
a great part in the etiology of arteriosclerosis. 



HYPER-TENSION 23 

Especially does SYPHILIS in the parents leave its 
stigma in the succeeding generations in the shape 
of poor arterial tissue which is thrown into earlier 
degeneration. No age is exempt from the lesions 
of arteriosclerosis. Fisk (15) maintains that 
proper diagnostic technique would show lesions 
quite constantly in persons of very early age. 
However, it is most generally seen in persons past 
middle life. It may occur in infants. Cerebral 
Hemorrhage in a child of two years has been seen. 
In these cases there is generally no question as to 
the existence of Lues. Hyper-tension, as a too oft 
repeated natural process of compensation, may 
cause arterial thickening. According to Warfleld, 
(16) hyper-tension per se holds first place as a 
cause of true arteriosclerosis. 

Occupation and Manner of Living. — Occupation 
entailing prolonged exercise and exposure or 
psychic activity, accompanied by worry will cause 
hyper-tension. Thickened arteries are simply a 
visible factor in the response of the human econ- 
omy to the unnatural demands made upon it by 
the strenuousness of our modern life. The strain 
of business, and to an extent the strain of certain 
recreation on business men, and the policy of 
"speeding up" applied to the laboring classes, has, 
in both alike, produced its own pathology- 
SEXUAL CONTINENCE is also sometimes 
blamed. ALCOHOL and DRUG INTOXICA- 
TIONS are no doubt potent factors in the etiology 
of arteriosclerosis. OVEREATING: There can be 
no doubt but that the constant overloading of the 
stomach with rich or difficultly digestible food is 
responsible for a large number of cases of arterio- 



24 BLOOD PRESSURE SIMPLIFIED 

sclerosis. Everyone must have noted the increase 
in force and volume of the heart beat after the 
ingestion of a large meal. The constant repetition 
of such processes can conceivably lead to damage 
to the vessel walls through hyper-tension. 
RENAL DISEASE is a certain producer of 
hyper-tension. It is very probable that in any 
case of hyper-arterial-tension, existing for some 
time, renal disease is present, even though there 
may be no signs directly referring to the kidneys. 

Diagnosis. — The blood-pressure in arterioscle- 
rosis is generally high. On the other hand Fisk 
(15) states that "low blood-pressure was fre- 
quently found with marked thickening andKa sur- 
prisingly slight degree of thickening in cases with 
fairly high pressure (180 and 190) , and absolutely 
no thickening in other cases of fairly high pres- 
sure, raising a question as to whether the part 
played by mechanical factors in causing thicken- 
ing has not been over estimated and the toxic and 
bacterial factors underestimated." However, the 
highest readings are always accompanied by renal 
involvement. There is usually more or less cardiac 
hypertrophy, which manifests itself by the usual 
signs. 

Very little reliance is to be placed on the pres- 
ence of palpable arteries, as there may be consider- 
able sclerosis at some portions of the arterial tree 
and not at others. 

Ophthalmoscope. — An ophthalmoscopic examin- 
ation is never to be forgotten. According to War- 
field (16) "It would not exaggerate too much to 
say that the examination of the eye grounds with 
the ophthalmoscope is a most important aid in the 



HYPER-TENSION 25 

early diagnosis of arteriosclerosis. Long before 
there are any subjective symptoms, changes may 
be seen in the blood vessels of the retina, which, 
while not always diagnostic, at least call attention 
to a beginning chronic disease. As I become more 
proficient in the use of the ophthalmoscope, I am 
impressed with the importance of the ocular signs 
of arterial disease. I would urge practitioners to 
familiarize themselves with this instrument." 

Symptoms. — "Symptoms usually complained of 
are dependent on the part involved. With renal 
involvement, there is headache, quite frequent and 
severe. Patient also complains of pain or pains 
all over the body, dizziness and dyspnea." War- 
field (16). 

The onset of arteriosclerosis is generally ex- 
tremely insidious. L. Renon (17) mentioned con 
tinuous morning headaches as one of the early 
symptoms, especially on thinking, the "Painful 
Thinking," of Josue. 

Numbness and tingling of the hands and feet, 
arms and legs are also complained of, also occa- 
sional epistaxis. Frequently there may be some 
slight edema of the ankles. Dyspeptic symptoms 
are common. 

Visceral Sclerosis — Visceral Sclerosis is nearly 
always accompanied by pain in the abdomen, in 
some cases there is vomiting, backache, tenderness 
over the epigastrium, and there may be psychic 
disturbances. 

Prognosis — An accurate prognosis in arterio- 
sclerosis is no easy matter. The most that may be 
said is that arteriosclerosis is always a serious dis- 
ease from the time its symptoms make themselves 



; 



26 BLOOD PRESSURE SIMPLIFIED 

known. The gravity depends altogether on the 
seat of the greatest arterial changes. It is neces- 
sarily greater when the seat is in the brain than 
when it is in the arms or legs. Give always a 
guarded prognosis — Warfield. (16) . 

Nephritis — Renal Disease (quoting again from 
Warfield (16) Chronic Disease of the Kidneys is 
one of the most certain producers of hyper arterial 
tension, in fact, some maintain that high tension 
even without demonstrable kidney lesions, as re- 
vealed by careful urine examinations, is a valuable 
sign pointing to chronic nephritis. Just what 
causes the increase in blood-pressure, sometimes to 
over 270 mm. of hg., is not definitely known. L. 
seems most probable that it is some poison elabor- 
ated by the diseased kidneys and absorbed into 
the general circulation. There it acts primarily 
on the musculature of the arteriols, causing tonic 
contraction and an increase of work on the part of 
the heart to force the blood through narrowed 
channels. One fact is certain: we see patients 
with blood-pressures much over 200 mm. of hg., 
as these cases clear up the pressure falls and 
should they seemingly recover, the recovery is 
accompanied with a marked decrease in blood pres- 
sure, finally reaching the normal for the individ- 
ual. Moreover, in the course of severe acute or 
subacute nephritis, hyper-tension is associated 
with headache, partial or total blindness and 
drowsiness. When the pressure is reduced, all 
these symptoms disappear. 

There is usually the chronically shrunken and 
scarred kidney, known pathologically as the 
"arteriosclerotic kidney." It is possible that there 



HYPER-TENSION 27 

are two groups of cases which we may designate : 
primary and secondary. In the primary group the 
kidney disease antedates the sclerosis of the 
arteries, and the sclerosis is most probably 
dependent on the constant high tension. We know 
that prolonged hyper-tension will produce severe 
forms of arteriosclerosis. The arterial disease in 
this group is caused by the renal disease. 

In the second group the kidney changes are 
apparently due to the general arteriosclerosis 
which, affecting the kidney vessels, causes changes 
leading to atrophy and subsequent fibrous tissue 
growth in scattered areas. These cases are not 
necessarily associated with hyper-tension; on the 
contrary there is more apt to be hypo-tension. 
Where the first group occurs for the most part in 
young and active middle aged people, the second 
group is the result of involuntary processes which 
accompany advanced age. 

We have learned that, no matter how careful 
the analysis of the urine may be, we cannot be 
sure of the pathological state of the kidney which 
secretes the urine. Too often so called normal 
urine, which contains considerable albumen and 
many casts, may be secreted by a kidney almost 
perfectly healthy, the lesions being only of a tran- 
sient and trivial nature — Warfield (16) . 

These cases show us a high diastolic and systolic 
pressure. The high diastolic usually obtaining in 
the later stages of the disease. A point in the 
therapeutic diagnosis mentioned by Elliott (18) 
is the very unsatisfactory response of these condi- 
tions to treatment. The mortality is high, the 
causes of death being heart failure, uremia and 



28 BLOOD PRESSURE SIMPLIFIED 

apoplexy, in their order of frequency. The highest 
average of both systolic and diastolic pressures 
known occurs in these cases. 

Uremia — Uremia is always accompanied with 
a very high blood-pressure; so high indeed as to 
be of great diagnostic import. The cause of the 
constant rise is not definitely known, but is prob- 
ably due to circulatory toxins, as defective elimin- 
ation is one of the main factors of the disease. 

Auto Intoxication — Auto Intoxication is usually 
accompanied with a high systolic pressure, due to 
the vasoconstriction and spasms of the arteries 
before actual organic change has taken place. In 
this condition some circulating pressor substance 
is present in the blood generated in the intestinal 
tract by bacterial action. One of these pressor 
substances is supposed to be Hydroxyphenoethyla- 
mine — a split product from Tyrosin. 

There may be hypo-tension also, as Barger and 
Dale (19) have succeeded in isolating a toxic 
depressor base from the intestinal mucosa. 

Angina Pectoris — The chief factor in the causa- 
tion of this disease is coronary sclerosis, and the 
blood pressure is usually affected according to the 
extent of the arterial change. During the attacks 
the pressure may rise or fall and in the intervals 
there may or may not be an elevation of the pres- 
sure. The recognition and treatment of those 
cases accompanied by high pressure is often 
attended by considerable relief and may entirely 
prevent the attacks. 

Valvular Lesions — With the exception of aortic 
insufficiency, compensated valvular lesions of the 
heart present but little variation from the normal. 



HYPER-TENSION 29 

The principal value of blood pressure examina- 
tions in these diseases is to establish the condition 
of the heart muscle, and as a guide to the prog- 
nosis and general management. The information 
gained indicated the efficiency of the treatment, 
the proper dosage and the interval of administra- 
tion. 

Aortic Regurgitation — Blood-pressure examina- 
tions in aortic insufficiency show a constantly high 
pulse pressure, which is almost pathognomonic, 
and by which a diagnosis is often first made. The 
high pulse pressure may be due to a fall of the 
diastolic pressure (Sys. 120. Dias. 50 Pulse Pres- 
sure 70) as is most common in the endocarditic 
group, or to a considerable rise in the systolic 
pressure, with relatively little change in the dias- 
tolic (Sys. 170 Dias. 90 Pulse Pressure 80) as is 
usual in the arteriosclerotic group. 

Asphyxia — If an animal is deprived of oxygen, 
phenomena ensues which produces a picture 
which we call asphyxia. 

If the deprivation be sudden, as in tying off the 
trachea, death occurs inside of five minutes and 
is preceded by convulsions. Where suffocation is 
more gradual, as in a closed chamber, convulsions 
do not appear and life is more prolonged. 

In addition to the motor and respiratory mani- 
festations with dyspnea, however, there is a strik- 
ing effect upon the vaso-motor and vagus centers. 

In the first stage, during which the respiratory 
center is stimulated and breathing is rapid and 
deep, the vasomotor center in the medulla is also 
thrown into action and a marked rise in blood- 
pressure occurs, which is accompanied by increas- 



30 BLOOD PRESSURE SIMPLIFIED 

ing slowness of the pulse and simultaneous activ- 
ity of the vagus center. 

In the latter stages, as the irritability of the 
respiratory center becomes exhausted, the other 
bulbar centers likewise fall. Then the spinal vaso- 
motor centers begin to act and the blood-pressure 
is maintained at a high level, with increasing 
heart rate, and spasmodic ineffectual respiratory 
action, only to fail during the last seconds of life, 
when the spinal centers have become utterly 
exhausted. 

An extreme rise of blood-pressure caused by 
asphyxia, and in a lesser degree by slighter grades 
of deficient oxygenation of the blood, is of distinct 
clinical import, as in the study of arterial pres- 
sure in cardiac and lung conditions, laryngeal 
diphtheria, etc. 

Alcohol — Alcohol exercises marked pressor 
effect on blood-pressure and acts as a circulating 
poison. 

Brain Tumor, Cerebral Hemorrhage, Menin- 
gitis, Increased Intracranial Tension, Apoplexy, 
Cerebral Thrombosis, Fracture of the Skull, In- 
tracranial Hemorrhage, Rapid Growing Brain 
Tumor and some cases of Uremia — in these con- 
ditions undoubtedly will be found the highest 
blood-pressures recorded in disease. 

Hirschf elder (1) says "Maximal blood-pressure 
may rise to 300 or 400 millimeters, minimal to 
160 or over, pulse rate low, 60 or under." 

Cushing has shown that when the intracranial 
tension rises above the blood-pressure, anemia of 
the vasomotor center brings about a tremendous 
vasocontraction and action of the augmentor 



HYPER-TENSION 31 

fibres in increasing the strength of the heart beat. 
The blood-pressure rises in successive stages 
(Traube-Hering Waves) until the mean pressure 
exceeds the intracranial pressure. The rise of 
blood pressure expresses the need of the brain for 
blood, to counteract the vasoconstriction with 
nitrites or other vasodilators, or venesection only 
increases the task of the heart. — Hirschf elder. (1) 



CHAPTER III 

HYPO -TENSION 

Definition — Transitory Lowerings Due to Physiologic 
Causes — A Consideration of Hypo-tension in Relation to 
the Diseases in Which It is a Factor — Summary. 

Definition — By hypo-arterial tension is meant a 
condition in which the pressure of the blood in the 
arteries is below a point which is generally asso- 
ciated with a normal or optimum function of the 
economy. (See Normal Blood-Pressure Page 17) . 

TRANSITORY LOWERINGS DUE TO 
PHYSIOLOGIC CAUSES 

The blood-pressure does not physiologically so 
often fall below the normal limit, as has been sup- 
posed. 

Micturition — Micturition reduces the blood- 
pressure temporarily. 

Exercise. — After rather prolonged exercise in 
a very well trained man, there is a slight fall of 
pressure. 

Hunger — Hunger in all probability lowers 
blood-pressure. 

Atmospheric Influences — Miller, J. A. (20) — As 
was mentioned in Chapter 1, blood-pressure is, to 
a certain extent, affected by humidity. The higher 
the humidity, the lower the blood-pressure. This 
should always be thought of when there is a wide 
variation between readings of different days. In 
fact, the practice of checking a blood-pressure 
reading with a hygrometer reading is one which 

32 



HYPO-TENSION 33 

will explain a great many otherwise puzzling prob- 
lems and lead to much greater accuracy in statis- 
tics. Staehelin (21) finds that a fall of barometer 
pressure causes temporary hypo-tension. 

A CONSIDERATION OF HYPO -TENSION 

IN RELATION TO THE DISEASES 

IN WHICH IT IS A FACTOR 

SUMMARY 

General — Bishop (22) would have us believe 
that a so-called essential hypo-tension exists quite 
frequently and that this fact has been very much 
underestimated. Individuals of apparent health, 
but who tire easily and are subject to every pass- 
ing infection, have a splanchnoptosis, complain 
of headache, etc., are many times causes of hypo- 
tension. One of the common symptoms of low 
blood-pressure is headache, which is always re- 
lieved when the blood-pressure is raised. 

Tuberculosis — Pulmonary tuberculosis pre- 
sents the classic picture, clinically, of hypo- 
arterial tension. 

Very often patients in w T hom no evidence of 
tuberculosis is found show their predisposition to 
this disease by continual low blood-pressure. 
This statement is so well borne out, that given 
a patient living in unhygenic surroundings a per- 
sistently low blood-pressure, should always put us 
on our guard. Once the lung has become the site 
of a tubercular focus the blood-pressure drops as 
the ravages of the disease advance and by the 
same token a rise in blood-pressure is of favor- 
able import. 



34 BLOOD PRESSURE SIMPLIFIED 

The systolic pressure is usually affected more 
than the diastolic and the resultant narrowing of 
the pulse pressure range is a bad indication. As to 
the cause, nothing definite is known. "The causes 
of low blood-pressure in tubercular hypo-tension 
are probably primarily a toxic action on the vaso- 
motor center of the medulla, allowing of a vaso 
paresis, or stimulating an active vaso-dilatation, 
and secondarily, progressive cardiac atrophy, or 
degeneration" — Emmerson ( 23 ) . 

Typhoid Fever — Typhoid Fever alone in almost 
every case is accompanied by a low blood-pressure, 
as are in fact almost all of the infectious diseases. 

From the end of the first week of the disease 
the pressure begins to fall and will generally con- 
tinue to fall until about the end of the fourth 
week ; even in some cases going as low as 90 mm. 
systolic pressure with a high diastolic. After the 
fourth week, in a favorably progressing case, the 
pressure will begin to rise gradually. A decided 
marked rise in pressure always precedes a per- 
foration — Crile (24). By keeping close blood-pres- 
sure records one can differentiate between the 
collapse from hemorrhage and intestinal perfora- 
tions. Where peritonitis exists, the fall in pressure 
is extreme and the condition fraught with danger. 

Rolleston's (12) series seems to show a per- 
sistent hypo-tension for many weeks after conval- 
escence is well established. 

Pneumonia — The record is low blood-pressure 
in the first stages of the disease; there may be a 
transitory hyper-tension but, as in nearly all acute 
infectious diseases, there is a steady decline. A 
rapid drop should lead us to look for cardiac dila- 



HYPO-TENSION 35 

tation. The severity of the disease is, to a certain 
extent, a function of the blood-pressure, varying 
directly. Shortly after the crisis blood-pressure 
will rise. 

In this connection the relation of the heart load 
to blood-pressure has received considerable atten- 
tion under the title of GIBSON'S RULE. 

"When the systolic pressure expressed in milli- 
meters of mercury does not fall below the pulse 
expressed in beats per minute, the fact may be 
taken as an excellent augury, while the converse 
is equally true, i. e. : when the pulse rate per 
minute is higher than the pressure of the milli- 
meters of mercury, the equilibrium of the circula- 
tion is seriously disturbed." 

Fraenkel (25), quoted by Janeway, finds a sub- 
normal pressure the rule, especially at the time 
of the crisis. In one third of his cases, however, 
it was absent. 

There has been a great deal of discussion on the 
matter of this rule, but the general consensus of 
opinion to-day would seem to favor it. However, 
these seems to be considerable evidence to show 
that a too pessimistic prognosis should not be 
placed on a hypo-tension alone. 

Gilbert and Castaigne (26) put forth that in 
favorable cases the tension never decreases mate- 
rially. There seems to be considerable diurnal 
variation, which should prevent us from drawing 
conclusions on a single reading. 

Scarlet Fever, Diphtheria, Measles and Rheu- 
matism — All acute infectious diseases, excepting 
Meningitis, and possibly Nephritis, are accompan- 
ied by low blood-pressure. A renal involvement 



36 BLOOD PRESSURE SIMPLIFIED 

may serve to raise the blood-pressure slightly. 
High blood-pressure in any infectious disease 
should lead to a careful elimination of Meningitis 
and Nephritis, before committing ourselves to a 
diagnosis. 

Syphilis — The blood-pressure in syphilis varies 
according to the stage of the disease and the anat- 
omical site of the lesions. During the chancre, or 
primary period the blood-pressure is low. During 
the secondary and tertiary stages, the latter par- 
ticularly, there is an arterial involvement which 
usually means hyper-tension. 

Syphilis has a predilection for the aorta and a 
high pulse pressure in known syphilitics would 
lead us to suspect an aortic regurgitation. 

Glandular Extracts — Although Falta, Schaefer 
and Sajous have done a great deal in the science 
of endocrinology, we are yet only able to apply 
clinically a few preparations of the internal 
secretions and this largely on an empirical basis. 
It would seem, however, that some day our thera- 
peutic armamentarium will receive many rein- 
forcements from this source. 

With the exception of adrenalin extracts and 
preparations of the hypophesis cerebri, posterior 
lobe, the intravenous injection of glandular prep- 
arations causes a lowering of the blood-pressure. 

Altitude — Altitude causes a slight fall in pres- 
sure in the normal individual. Acclimation 
brings the pressure back to normal. The suscep- 
tibility of individuals differs widely. A given 
amount of exercise in a high altitude produces a 
higher arterial tension than the same amount at a 
lower altitude in an untrained man. 



HYPO-TENSION 37 

Epilepsy — Between seizures the vascular ten- 
sion shows very little change. During the seiz- 
ures there is a rise due to muscular contraction ; 
following this there is considerable fall for some 
time. 

Arteriosclerosis — Arteriosclerosis is again men- 
tioned at this point to emphasize the occasional 
existence of low blood-pressure. Especially in the 
generalized or defused type there is usually a low 
blood-pressure. These cases show myocardial 
change, such as brown atrophy and some connect- 
ive tissue formation. 

The probabilities are that a refined technique 
will show thickened arteries in a number of 
patients with decreased vascular stress. Fisk 
(15) speaking in this connection advises the fol- 
lowing method: "The circulation in the radial, 
or other artery that is being palpated, is cut off 
by pressure of the index and ring fingers. The 
middle finger then carefully explores the artery, 
pressing it firmly down on the bone and noting 
whether the artery may still be felt either as a 
ribbonlike band, a thick tape, or a hard tube, 
depending on the degree of thickening. 

SUMMARY 

Summarizing our knowledge of low blood-pres- 
sure we may safely state that all acute infectious 
diseases are accompanied by a low blood-pressure 
excepting acute Meningitis, and possibly Ne- 
phritis. The increased intracranial tension here 
being responsible for a rise in blood-pressure. 

The injection of glandular extracts, except 
adrenalin and pituitin will decrease the blood- 



38 BLOOD PRESSURE SIMPLIFIED 

pressure. With negative clinical findings a low 
blood-pressure would lead us to suspect tuber- 
culosis. 



CHAPTER IV 

DISEASES IN WHICH BLOOD PRESSURE 
IS NOT DEFINITELY KNOWN 

There is a certain class of diseases which, while 
they are usually accompanied by alterations in 
the blood-pressure, seem to have no constant 
effect on the vascular regulating mechanisms. 
One observer will report one change while an- 
other will be at variance, or we may even find a 
great difference in individual experience. Recent 
investigation with improved instruments have 
taken many diseases from their classic categories 
in this respect and thrown them into an entirely 
different group. 

EXOGENOUS INTOXICATIONS 

Plumbism — Plumbism has always been consid- 
ered an intoxication accompanied by a high blood- 
pressure, but is now believed to have nearly a 
normal blood pressure, or only hyper-tension dur- 
ing attacks of colic. 

Morphinism — Some observers, Pettey (27) 
report high blood-pressure in morphinism. This 
is laid to portal congestion induced by constipa- 
tion. Inasmuch as many believe constipation may 
be accompanied by low blood-pressure the above 
statements must be accepted with considerable 
reserve. 

In these cases, however, thorough elimination 

39 



40 BLOOD PRESSURE SIMPLIFIED 

brought about a rise of blood-pressure. Results 
of Valenti's (28) works lead us to believe that 
stimulation of the circulation may be necessary 
at times during the withdrawal stage of the treat- 
ment of morphinism. 

Tobacco — There has been much discussion as to 
the physiologic effect of tobacco and so far noth- 
ing very definite is known. 

Cannon (29) says that blood-pressure is raised, 
due probably to a stimulation of the suprarenals 
by the sympathetic. There has also been consid- 
erable discussion as to whether the constitutional 
effects which follow the use of tobacco are due 
to nicotine or other substances. 

No doubt carbon monoxid plays an important 
part. According to some authorities hydrocyanic 
acid, f urf urol and other aldehydes have also to be 
reckoned with. Lehman (30) has shown that the 
slower the rate of smoking the smaller amount of 
hydrocyanic acid forms. 

Blood-pressure is increased only partly through 
stimulation of the vasoconstrictor center of the 
medulla. It is chiefly the peripheral influence as 
it occurs even after extirpation of the spinal cord. 

Lee (31) apparently succeeded in producing 
definite vascular lesions in rabbits, which were 
made to inhale tobacco smoke over prolonged 
periods of time. 

The withholding of tobacco is an important 
point in the therapy of arterial hyper-tension, 
arteriosclerosis and also in heart disease. 

Acromegaly — Chronic disease of the pituitary 
body produces a low blood-pressure, according to 
most observers. Some, however, have reported 



BLOOD PRESSURE NOT DEFINITELY KNOWN 41 

cases associated with increased vascular stress. 
These statements are in part reconciled by 
Brown (32), who states that blood-pressure bears 
a close relation to the sugar tolerance, being low 
at first and high after the disease has progressed. 

Addison's Disease — Vascular stress is extreme- 
ly variable and capricious in Addison's Disease. 
It seems to have no relation to either the clinical 
symptoms or pathology, except possibly hypo- 
tension is most frequent with medullary involve- 
ment. 

Gout — Of the blood-pressure in this disease 
nothing is definitely known. A consideration of 
its pathology would make one expect hyper- 
arterial tension, but as the disease itself is 
usually masked clinically by renal or other 
lesions we cannot be safe in ascribing a concomi- 
tant hyper-tension. 

Diabetes — There is a growing conviction with 
many investigators that blood sugar and urine 
sugar are in some ways related to vascular stress. 
The work of Lee and Scott (33) has shown that 
high humidities reduce blood-pressure and also 
blood-sugar, which would seem to furnish corrob- 
orative evidence of Neubauer's statement. 

Status Lymphaticus — Nothing is known defi- 
nitely as to the effect of thymus disease on blood- 
pressure. Patients in whom this complex appears 
are sub-normal in every way and the low arterial 
tension is probably simply an incident. 

Obesity — So far as is known there are no spe- 
cific alterations in blood-pressure accompanying 
obesity. 

Dunin has found that a decrease in pressure 



42 BLOOD PRESSURE SIMPLIFIED 

in obese patients is usually associated with a loss 
of weight. However, if the circulatory system is 
normal a loss of weight does not affect blood-pres- 
sure. 

Faber (34) reports a very frequent hyper- 
tension (50% in his series.) Dyspepsia is incrim- 
inated as being a factor because of its producing 
an elevated pressure before there is much obesity. 

Myxedema — Myxedema is quite frequently ac- 
companied by a hyper-arterial tension. 

Anemia — Blood-pressure determinations are 
very valuable in this disease as they may elim- 
inate a renal factor in the production of the pecu- 
liar palor and weakness. Nephritic complication, 
of course, raises the pressure. 

Cachexia — A cachexia from any cause such as 
malignancy may mask the blood-pressure findings 
in concomitant lesions which would otherwise 
show themselves in the blood-pressure findings. 

Neurasthenia — In Neurasthenia, characterized 
by Bishop (22) as "pathologic fatigue," the blood- 
pressure is subject to considerable variation. In 
true neurasthenia, due to the exhaustion of the 
nerve centers, the pressure is low, while a similar 
symptom complex, due to circulation of toxins 
from the digestive tract, is accompanied by high 
pressure. The blood-pressure examination is of 
aid in differentiating the two conditions. 

Dementia Praecoxi — Blood-pressure is nearly 
always low, probably due to the general subnor- 
mal condition of these patients. 



CHAPTER V 

THERAPEUTICS OF ABNORMAL 
BLOOD -PRESSURE 

Introduction — Hypo-tension — Physical Therapeutics — 
Drug Therapy — Dietetics — Hyper-tension — Physical Ther- 
apeutics — Drugs — Diet — General Conclusion and Sum- 
mary. 

From a therapeutic standpoint, arterial and 
cardiac diseases form a unique group, insomuch 
that co-operation of the patient is absolutely 
necessary. Considering the etiology, particularly 
of hyper-tension, it is obvious that the patient's 
condition is due in a large measure to an error 
in his habits of living. The correction of this 
error is of first importance in the treatment, and 
without the patient's co-operation our best 
directed efforts must inevitably fail. 

The problem is frequently rendered more diffi- 
cult by the patient's firm conviction that the 
habits which we know to be pernicious are harm- 
less and essential to his enjoyment and comfort. 
There are, of course, exceptions : now and then we 
find a man who has been a "high liver," arriving 
at the age of 40 with a badly impaired physique 
who is willing and even anxious to co-operate 
with us and go to any length to undo as much of 
the evil as possible. Needless to say, these cases 
offer an immeasurably brighter prospect, from 
the standpoint of prognosis, other things being 
equal, than the great majority with which we 
have to deal. 

43 



44 BLOOD PRESSURE SIMPLIFIED 

PHYSICAL THERAPEUTICS- 
HYPO -TENSION 

The application of the measures of physical 
therapy to the relief of hypo-tension is usually 
productive of much good, although they do not 
occupy the high place that they do in hyper- 
tension. We are oft trying to combat a constitu- 
tional make-up and not an acquired condition, as 
we find in increased arterial tension. 

Rest— Rest is a great therapeutic dissideratum ; 
that is, temper the patient's exertion to the nour- 
ishment available. Especially in those cases who 
are mentally overworked, a lightening of the bur- 
den and prescribed periods of rest, say eight 
hours at night and one or two hours daily ( after 
the noon meal), will frequently give a marked 
improvement. 

Exercise — A certain amount of exercise, pre- 
ferably taken outdoors, is also necessary, but it 
should not be prolonged or of the competitive 
type. The patient should be cautioned against 
overdoing in the matter of exercise and should 
stop upon becoming slightly fatigued (see under 
blood pressure in athletics). 

Hydrotherapy — Cool baths (75° F.) raise 
blood-pressure and are indicated in practically 
all cases of hypo-tension. They should be used 
with considerable discretion, as increased peri- 
pheral resistance may throw such a burden on an 
already weak heart that syncope might ensue. 
There is no doubt, however, of their value in the 
majority of cases of hypo-tension. A cool plunge 
may be beneficial, taken on rising. 



THERAPEUTICS OF ABNORMAL BLOOD PRESSURE 45 

Spray Baths — It is to be remembered that the 
great benefit of cool baths is derived largely from 
the friction applied to the surface of the skin 
after the bath. This may be accomplished by 
simply rubbing, or better still by the needle bath 
in which numberless fine streams of water are 
allowed to play on the body. Another common 
method is to force the water through the hollow 
projections of the rubber brush used for this pur- 
pose. 

Carbonated Brine Baths — Carbonated Brine 
Baths do good in hypo-tension because of their 
cardiovascular tonic effect. Their action is com- 
parable to digitalis. 

DRUG THERAPY 

Tonics take first place among drugs in the 
treatment of low blood-pressure. 

The classic mixtures of iron, quinine and V 
strychnin should be administered three times a 
day, before meals. 

Potassium Iodid gives a benign effect in the 
luetic conditions, congential and acquired. 

Epinephrin — Epinephrin is administered per 
mouth, intravenously, intraspinally and hypoder- 
matically. The therapeutic indications of the 
drug and the methods of administration are not 
yet well worked out. Its best use is in combating 
decreased vasomotor tone where we have a relia- 
able heart. In fiive to ten minim doses, one to 
twenty-five thousand dilution, as saline infusion, 
it is indicated in shock and collapse during anes- 
thesia. 

Ammonium — Ammonium Carbonate or Aro- 



46 BLOOD PRESSURE SIMPLIFIED 

matic Spirits is a good cardiac stimulant, but its 
effects are very fleeting. 

Pituitary Extracts — The action of pituitary 
gland extracts is to increase ventricular contrac- 
tion and slow the pulse and increase peripheral 
resistance. These effects are longer than those 
due to adrenal extract. 

Strychnin — There is much discussion on the 
pharmocology of strychnin. The classic intoxica- 
tions are vasomotor depresssion of central origin. 
Recently massive doses have been exhibited with 
certain favorable effect. 

DIETETICS 

Diet requires attention in hypo-tension as well 
as in hyper-tension. 

One of the first considerations after elimina- 
tion in the treatment of essential hypo-tension is 
the selection of a nourishing, non-constipating, 
anti-putrefactive diet. A depressor body has been 
isolated from the intestinal mucosa. This fact 
emphasizes the necessity of maintaining, as far 
as possible, bowel asepsis. 

HYPER-TENSION 

Before treatment is begun the physician should 
thoroughly inform himself as to the diet and other 
habits of the individual, particular attention being 
given to the history of acute diseases, or infec- 
tions, over indulgence in food, venery, alcohol, to- 
bacco, coffee, tea, recreation, business and domes- 
tic worries. 

The habits as regards the kind and quantity of 
food ingested and the time and manner of taking 



THERAPEUTICS OF ABNORMAL BLOOD PRESSURE 47 

will be shown by a carefully obtained history and 
a twenty-four-hour record. 

The urine should also be collected during this 
period and a complete chemical and microscopical 
examination of a mixed twenty-four-hour speci- 
men made. 

Hyper function in the adrenals with a lessen- 
ing of thyroid activity not infrequently follows 
the acute diseases and infections of early life. 
Disturbances of the internal secretions should be 
kept in mind in the investigation of every case of 
hyper-tension. 

PHYSICAL THERAPEUTICS 

Hot Baths — recently hot baths have been em- 
ployed in the treatment of vascular hyper-tension. 
The objection has been made that the lowering of 
blood-pressure occurs as a phenomenon of exhaus- 
tion after a preliminary rise. The danger period 
is during this preliminary rise and the patient 
should be carefully watched for some minutes 
after being immersed in hot water (105 to 110° 
F.) When beads of perspiration begin to ap- 
pear on the forehead, the patient should be 
removed from the bath. 

Warm Baths— Warm Baths (95 to 105° F.) 
are very important in the treatment of hyper- 
tension. They should be taken before retiring, 
with the water about body temperature. With a 
good heart a gradual vasodilatation occurs, which 
lowers the blood-pressure for some time and 
their repeated use will produce a permanent 
lowering. 

Nauheim Baths — Nauheim Baths are indicated 



48 BLOOD PRESSURE SIMPLIFIED 

in myocardial weakness. Sweating produces a 
lower blood-pressure, beside the good effect of 
elimination. It is indicated in impending uremic 
crises and renal involvement. 

Oxygen Baths — Oxygen Baths are regarded by 
many observers with considerable value. Baed- 
eker (35) says that they are contraindicated in 
anemia. 

Rest — A part of the symptoms of high blood- 
pressure are met by rest applied as a therapeutic 
procedure. Grossman (11) treats high blood- 
pressure very successfuly with muscular relaxa- 
tion. He says "with muscular relaxation for the 
purpose of reducing blood-pressure, we endeavor 
to induce a state somewhat similar to sleep, a 
state typefied by diminished spasm of the muscles 
of expression, and of winking, a state of muscular 
relaxation accompanied by regular effortless dia- 
phragmatic breathing." This last should receive 
a great deal of emphasis, as physical rest without 
mental equanimity is impossible. 

High-frequency Currents — D'arsonvalization 
has been considerably exploited as a treatment of 
hyper arterial tension. Some observers who are 
entirely competent aver that any good effect from 
high-frequency currents is due to its thermic 
action. Nevertheless, they seem to exert a benign 
influence on certain functional cases of vascular 
stress with mild renal involvement. 

Massage — In massage, blood-pressure is in- 
creased during the first part of the treatment but 
is lowered in its later stages. The greatest effect 
is on the elimination and the increasing of venous 
and lymphatic circulation. Abdominal massage 



THERAPEUTICS OF ABNORMAL BLOOD PRESSURE 49 

should be done by a skillful operator as, in hyper- 
tension, with much cardiac involvement, serious 
depression may occur. The good effect is due to 
the increase of intestinal peristalsis. 

Radium — The data on radium is so slight at the 
present time that very little may be said either in 
favor of or against its use. The usual method is 
per mouth in drinking water, or by bathing in 
radium charged water. 

Climate — Our data on climate and its relation 
to hyper-tension is rather meagre. It has been 
empirically worked out that renal cases do better 
in warm, dry, equitable climates, in not too high 
an altitude. High humidities lower blood-pres- 
sure, as is well known, but they exert so many 
other deleterious effects that the advisability of 
recomending them in the treatment of high blood- 
pressure would be questionable in the light of our 
present knowledge. 

Psychic Treatment — The only phase of sugges- 
tion which would appear in connection with high 
blood-pressure treatment would be the morbid 
introspection of the patient on being informed of 
his condition. It is well in this class of cases to 
refrain from any suggestion which might give 
him undue concern because of his condition. 

Respiratory Gymnastics — Systemic deep 
breathing in the open air is of value in both hyper- 
tension and hypo-tension. As to just what the 
changes induced are: physical, the volume of air 
change, blood flow and lymph circulation; chem- 
ical, changes in the respired air and blood, — we do 
not exactly know, but on the basis of elimination 
alone they will be indicated. 



50 BLOOD PRESSURE SIMPLIFIED 

DRUG THERAPY 

While the range of drug therapy in increased 
vascular stress is not so great as it was once 
believed to be, there are still certain drugs which 
meet well known indications and behave very con- 
sistently. 

Aconite — The use of Aconite in hyper-tension 
is extremely limited. It produces its effects by 
weakening of the myocardial contraction. da- 
Costa (36) found it of value in acutely strained 
hearts when used in combination with digitalis. 
Hirschf elder (1) affirms its value in post febrile 
tachycardia. 

Alkali — Alkali may serve to raise the alkaline 
index of the blood, thus neutralizing to a certain 
extent some of the products of bacterial putre- 
faction in the intestines. 

Pilocarpine — Robinson (37) highly recom- 
mends pilocarpine in small doses gr. 1/30 t. i. d. 
in water. It is a very active diaphoretic. 

We must remember that Busquet (38), quoted 
by Hart, has succeeded in producing experi- 
mentally an auricular fibrillation with pilocarpine. 

Thyroid Extract — It is chiefly indicated in 
women, after the menapause, suffering from nerv- 
ous derangements due to the cessation of the 
ovarine secretion and accompanied with hyper 
secreting adrenals. Its depressor properties are 
probably due to cholin. 

Belladonna — Atropin is sometimes of value in 
pulmonary edema. 

Caffein — Coffee is of value in collapse, the hot 
infusion being thrown into the rectum acts as a 



THERAPEUTICS OF ABNORMAL BLOOD PRESSURE 51 

temporary stimulant, causing a slight rise in 
blood-pressure. It also increases the secretion 
of urine. 

Camphor — Camphor in sterile oil may be in- 
jected hypodermically in shock. It usually pro- 
duces a transient increase in the pulse rate, and 
is a fairly good cardiac stimulant. 

Iodids — Iodids are one of our most valuable 
drugs in the treatment of arteriosclerosis. The 
physiological effect is not definitely known. Em- 
pirically, however, their place is assured and they 
are indicated in practically all the late stages. 

Viscum Album — (Mistletoe) — Mistletoe is 
mentioned by R. Gaulthier (39) and is used for 
the purpose of lowering blood-pressure. It is 
given in doses of about one-half drachm. 

Digitalis — Digitalis is our sheet anchor in 
myocardial lesions. It slows and strengthens the 
heart and is indicated in hypo-tension, due to a 
cardiac decompensation, or a weakening of the 
myocardium from any cause. It also aids in the 
nourishment of the cardiac musculature. A high 
pressure stasis may sometimes be relieved by the 
judicious use of digitalis. In emergencies, suit- 
able preparations of digitalis may be injected 
hypodermatically or intravenously. 

DIET 

No case of hyper-tension should be treated 
without careful attention to diet. If possible the 
diet should be figured on a caloric basis. The first 
requirement of the diet should be that it is non- 
putrefactive. The protein foods such as meats, 
eggs, fish, milk, cheese, beans and peas should be 



52 BLOOD PRESSURE SIMPLIFIED 

entirely eliminated during the early part of the 
treatment and allowed only in small quantities in 
the later stages. 

When the patient is first seen in an advanced 
stage complete starvation for several days is a 
very useful measure. This should be combined 
with the rest treatment. 

If kidney irritation is prominent the Karell 
diet — a glass of milk at 8-12-4 and 8, throughout 
the day — will be of service. When a more com- 
plete diet can be resumed, fruits should be eaten at 
each meal and when obtainable, green vegetables. 
At all times, however, fried foods, as well as 
pastries, hot breads, cakes, richly seasoned foods, 
tea, coffee, alcohol and tobacco should be for- 
bidden. 

In patients with good strong hearts and where 
the symptom complex seems to point largely to 
circulatory irritants, the liquid intake may be 
increased ad libitum. With an unreliable heart 
and organic hyper-tension, liquid should be 
limited, and taken by sipping on an empty 
stomach. 

GENERAL CONCLUSION AND SUMMARY 

Summary — Every patient is a law unto him- 
self and should be individually studied. His co- 
operation should be secured and he should be 
instructed that moderation be his watchward of 
living. A judicious combination of warm baths, 
rest, massage, corrected diet and possibly high- 
frequency current, if applied in the proper mental 
attitude, of both physician and patient, will in 
most cases bring favorable results. Drugs given 



THERAPEUTICS OF ABNORMAL BLOOD PRESSURE 53 

on specific indication are helpful. It is well to 
remember in this connection that "moderation" is 
a good word for the doctor. 



CHAPTER VI 

BLOOD-PRESSURE IN LIFE INSURANCE 

AND A CONSIDERATION OF THE TESTS 

FOR CARDIAC EFFICIENCY 

Present Status of Blood-Pressure Readings — Fisher's 
Tables — Method of Conducting Examinations — Tests for 
Cardiac Efficiency. 

Statistics collected in the past several years 
since blood-pressure determinations became essen- 
tial in life insurance examinations show conclu- 
sively the vital relation between longevity and 
arterial pressure variations. As our instruments 
and technique have improved, the value of the 
sphygmomanometric determination has been en- 
hanced, and it stands to-day at the very top of the 
list of our means of ascertaining an individual's 
actuarial classification. 

FISHER'S TABLES 

(See page 55) 

The painstaking and exhaustive investigations 
of J. W. Fisher, M. D., Medical Director of the 
Northwestern Mutual Life Insurance Company, 
have added a great deal to the knowledge of the 
value of blood-pressure readings in life insurance. 
In his latest work (40) he tabulates the record of 
2,630 accepted risks, ages forty to sixty, and hav- 
ing an average systolic pressure of 142 mm. The 
mortality in this class was 93.16 per cent. In 521 
accepted risks of the same ages, having an aver- 
age of 152.6 mm. systolic pressure, the mortality 

54 



BLOOD PRESSURE AND LIFE INSURANCE, ETC. 55 



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56 BLOOD PRESSURE SIMPLIFIED 

jumped to 127 per cent., while in 302 rejected 
risks, ages the same, and having an average sys- 
tolic pressure of 170 mm. with no other impair- 
ment, the mortality soared to 250.41 per cent. Dr. 
Fisher summarizes the mortality experience of 
his Company with respect to the systolic blood 
pressure in a descriptive chart (See page 55) and 
forms the following conclusions from his study 
of the subject: 

I. That a persistently high arterial tension 
will result in an excessive mortality, and the 
higher the arterial tension the greater the mor- 
tality. 

II. That a persistent systolic blood pressure of 
about 12 mm. above the average for the age would 
seem to indicate the limit of normal excess varia- 
tion in man. 

III. That an apparently healthy person may 
have high arterial tension extending over a con- 
siderable period of time without a discoverable 
impairment to account for same. 

IV. That of the medical impairments found, 
together with high arterial tension, both below 
and above the age of 40, more than 75 per cent, 
are cardiovascular. 

V. That while the normal average blood pres- 
sure increases with age so far as investigated 
(i. e., age 60 or 65), materially higher arterial 
tension is not necessarily to be expected at older 
ages. 

VI. That persons with a systolic blood-pres- 
sure between 90 and 110 mm. show a more favor- 
able mortality than persons with a pressure of 12 
mm. above the average pressure for the age. 



BLOOD PRESSURE AND LIFE INSURANCE, ETC. 57 

VII. That in persons whose weight is 20 per 
cent, or more in excess of the average for height 
and age, blood pressure averages about 4 mm. 
higher than those of normal weight. 

METHOD OF CONDUCTING EXAMINATIONS 

As was shown in a previous chapter, excite- 
ment, exercise, position, digestion, etc., influence 
blood-pressure to a marked degree, and as these 
factors are simply incidents in the life of the indi- 
vidual, the blood-pressure taken while being acted 
upon by their influence would not give us an index 
of the natural organic vascular level of the patient. 
Our report is but a flashlight on the physiology 
of the applicant, at best, and this picture must 
be taken during the normal natural quiescent 
period of the applicant's existence. 

The vascular tree is an organization in which 
the essential element is the ability to alter its 
shape almost instantly in response to small stim- 
uli originating in any part of the body. In answer 
to the vicissitudes of the day it is continually 
quivering and varying in every branch. Adopting 
this view of the circulation it is obvious that the 
success of our attempts at taking blood-pressure 
depends largely upon our method of approaching 
the patient and treating him during the prelim- 
inary stages of the test. Thus a patient coming 
hurriedly into our office, removing his outer gar- 
ments with considerable flourish and briskly pull- 
ing up a tight-fitting undershirt sleeve, will give 
us a picture of the amount of change which his 
arterial system is capable of undergoing, in 
response to a comparatively small stimulus, but 



58 BLOOD PRESSURE SIMPLIFIED 

his blood-pressure reading so obtained will be un- 
reliable. These cases should be handled in a quiet, 
calm and reassuring manner and cautioned 
against unnecessary exertion and excitement. 

In the case of timid, shrinking, frightened indi- 
viduals they should be assured of the painlessness 
of the proceedings, and in every way at our com- 
mand, we should endeavor to put them at their 
ease. Other things being equal, the actual taking 
of the blood-pressure should not be done imme- 
diately on the patient's entrance, but only after a 
sufficient time has elapsed to allow these emo- 
tional states to subside. 

Another item which should receive careful 
attention, if we wish to insure accuracy in our 
insurance examinations, is the time of day, in rela- 
tion to the patient's habits, at which the examina- 
tion is made. The examination should not be 
made when the applicant is fatigued, at the end of 
a hard day's work, nor immediately following a 
heavy meal. If the applicant is laboring under 
considerable mental stress from financial reverses, 
domestic trouble, or other causes of physiological 
hyper-tension this part of the insurance examina- 
tion had better be deferred until another time. 

Position — The effect of posture upon blood-pres- 
sure is not as yet definitely known, but whatever 
its influence may be it can be counteracted by 
always having the patient in the same position. 
Perhaps the best attitude is gained by seating the 
patient comfortably in a chair with the arm rest- 
ing on a table at about the level of the heart. 

Application of the Sleeve — While placing the 
sleeve on the arm the patient should be assured 



BLOOD PRESSURE AND LIFE INSURANCE, ETC. 59 

of the complete harmlessness of the test and it is 
well to gently inflate the sleeve for a few seconds, 
then release the pressure to accustom him to the 
somewhat unpleasant feeling of arm compression. 
The pulse rate may be counted at this time as both 
the blood-pressure and pulse readings should be 
taken under the same conditions. 

The auscultatory technique explained in Chap- 
ter I. should be followed. 

The actual work of taking the blood-pressure 
need consume at the outside only about two min- 
utes. With an experienced worker it should be 
done in a fraction of a minute. The examiner's 
mind should be concentrated on the work and the 
technique carried out as rapidly as possible. 

We can do a great deal to reassure the patient 
by removing the bulb from the tube of the com- 
pression bag immediately after the reading is 
taken. This insures a rapid and complete empty- 
ing of the bag, allowing the circulation in the arm 
to resume its normal state in a very short space of 
time and the disagreeable sensation of compres- 
sion of the arm is soon relieved. The more we do 
to overcome the patient's fears in the first exam- 
ination, the easier and more accurate will be our 
subsequent examinations. 

A word should be added in regard to the equip- 
ment of the physician's office for insurance exam- 
inations. Very few articles are required, but these 
should always be on hand and in proper working 
order. The most essential are — a good microscope, 
sphygmomanometer, an accurate, well designed 
urinometer, together with the necessary appar- 
atus and reagents for the estimation of indican, 



60 BLOOD PRESSURE SIMPLIFIED 

sugar and albumen, a pair of scales and a meas- 
uring rod for height, etc. Inasmuch as all 
insurance examinations should be made with the 
patient at least partly disrobed, the maintenance 
of comfortable temperature should receive careful 
attention. A low couch, aside from the usual 
examining chair, completes the equipment. 

Summarizing — Immediately on the patient's 
entrance to our office we should request him to 
remove his coat and waistcoat, and in a quiet reas- 
suring manner seat him comfortably and begin 
our preliminary questioning. The room should be 
warm and well lighted and all our apparatus con* 
veniently at hand. 

Both systolic and diastolic pressures should be 
routinely estimated and reported. While it is 
true that the diastolic pressure in the past has 
not been required by many of the companies, 
those requiring it are constantly increasing and 
there is but little doubt that the next few years 
will see it in general demand. 

FUNCTIONAL TESTS FOR CARDIAC 
EFFICIENCY 

While in life insurance examinations we wish 
to have the individual at complete rest, when we 
wish to know something of the capacity of the 
heart to respond to functional demands, we must 
examine the individual immediately after a period 
of physical exercise, or after the heart has been 
subjected to some unusual stress. 

A number of tests have been proposed, utiliz- 
ing various methods of temporarily increasing 
the burden of the heart. From experiment we 



BLOOD PRESSURE AND LIFE INSURANCE, ETC. 61 

know that a normal heart should respond to an 
increased demand with certain characteristic 
changes in rate and output and its functional effi- 
ciency is determined by any or all of these mani- 
festations. 

An efficient test, modified after Graupner's 
(41) is as follows: The pressure sleeve is snugly 
applied to the bare left arm and during the active 
part of the following procedure the bulb and 
instrument may be carried by the patient, the 
left arm being held well up, to prevent the cuff 
from slipping down and causing any after delay 
in determining the pressure. 

First — The diastolic, systolic and pulse pres- 
sures and the pulse rate are carefully taken with 
the patient in a sitting position, care being taken 
to see that the patient is at ease, with muscles 
fully relaxed. The color of the skin, the circula- 
tory and respiratory conditions are carefully 
noted. A record is made of these findings. 

Second — The patient is now put up one or two 
flights of average stairs at a reasonable speed, or 
subjected to a series of bending or high stepping 
movements, and the pressure is determined imme- 
diately thereafter. No time should be lost in 
determining the pressures following this exercise, 
since in some instances the systolic pressure may 
drop as much as 15 mm. or more in one minute. 

Third — The patient should now be comfortably 
seated with the arm supported on a table and 
entirely relaxed for five minutes. During this 
interval the pressure should be determined every 
two minutes. 

Normally both systolic and pulse pressures and 



62 BLOOD PRESSURE SIMPLIFIED 

pulse rate show an increase after the exercise, 
with a return to normal after the period of rest. 
The diastolic pressure usually falls a few milli- 
meters, but may show a slight rise or remain un- 
changed. 

A change in the systolic and pulse pressures, 
immediately or after a transitory rise, and a 
delay of their return to normal, indicates myo- 
cardial weakness. 

A lowered pulse pressure, associated with a 
marked increase in pulse rate, is a definite sign 
of impaired efficiency. 

Katzenstein's Method (42) — The exclusion of 
an amount of blood from the circulation (by con- 
stricting of the thigh) alter the heart beat and 
affect pressure perceptibly. We make use of it 
in the treatment of angina pectoris, where it 
lowers (sometimes elevates) pressure and usual- 
ly slows the pulse rate. 

The Katzenstein method of testing the func- 
tion of the heart is based on the observation that 
on digital compression of both femorals blood- 
pressure of the healthy will rise from 10 to 20 
mm., while the pulse rate remains the same. In 
a weak heart, however, the pressure remains on 
the same level, or is lowered, while the pulse rate 
is apt to increase. Also the absorption of very 
large amounts of water (intravenous infusion, 
excessive drinking) lowers blood pressure normal- 
ly— Richter (7). 

Crampton's Test (43) — Crampton's test of 
vasomotor efficiency. This test rests on the re- 
sponse of the heart to changes of posture. Inas- 
much as there is a great deal of uncertainty 



BLOOD PRESSURE AND LIFE INSURANCE, ETC. 63 

regarding the effect of posture, the usefulness of 
this test is perhaps very slight. 

The patient should be placed in a horizontal 
position and the heart observed until the rate 
becomes regular after several minutes. He is 
then allowed to stand and the heart rate again 
counted until it becomes uniform after several 
periods. The difference in rate and pulse pressure 
are calculated and reference is made to a scale. 
This method has the advantage of being able to 
give a numerical value to a functional, cardiac 
and vasomotor condition. 

Cardiac Aptitude — Lian (44) has devised a 
method of judging the heart condition by its rate 
before and after short periods of exercise. Ascer- 
tain the normal standing pulse rate by having the 
patient flex the legs on the thighs (a high stepping 
action) to a right angle, for five minutes, a 
rhythm of two per second being maintained. At 
the close of the five second period, with the patient 
in an erect position, the pulse is again counted 
and at intervals of forty-five seconds thereafter 
until the pulse attains the rate manifested before 
exercising. If this occurs by the second minute 
he is rated as 100. If the pulse is still high at the 
fifth minute that patient is pronounced a bad risk. 

Cautions. — For obtaining the record of ad- 
vanced cases unable to go through the exercises as 
above outlined, a few bending movements, or the 
variation of pressure noted in changing from the 
reclining to the sitting or standing position, may 
be used. 

Cyanosis or dyspneoa appearing during or 
after the exercise is definite evidence of impair- 



64 BLOOD PRESSURE SIMPLIFIED 

ment and where they are marked and appear early 
in the exercise the tests should be discontinued or 
proceeded with very cautiously. 

As the value of the tests rests largely on know- 
ing the circulatory conditions immediately after 
the exercises, it is very essential that the physi- 
cian have a high degree of proficiency in technique, 
otherwise a significant change may pass unnoticed. 

To avoid delaying the readings, the pressure 
sleeve should be snugly applied, so that it will not 
slip down, and the patient should carry the instru- 
ment so as to disturb its position as little as 
possible. 

Accurate results are possible only by the use 
of the auscultatory method. 

In athletes, or those who have accustomed them- 
selves to strenuous forms of exercise, the greatest 
exercise to which they are accustomed should be 
employed. The above movements are applicable 
to the large number of individuals of moderately 
active habits and occupation. 

The mercurial type of instrument is entirely 
inadequate for this use, as the readings must be 
taken immediately after the exercises. In the case 
of the diaphragm instrument the bulb and dial 
may be worn during the test, and the readings 
may be made almost co-incidently with the cessa- 
tion of the exercises. 

Blood-pressure in Athletics — Any individual 
before engaging in the pursuit of the more stren- 
uous forms of competitive athletics, as Equestrian 
Polo, Rugby, Marathon Racing, etc., should under- 
go a thorough physical examination, especial 



BLOOD PRESSURE AND LIFE INSURANCE, ETC. 65 

emphasis being laid on the heart and vasomotor 
efficiency. 

No man with even the slightest impairment 
of the heart, as manifested by cyanosis, undue 
increase in the heart load, or respiratory embar- 
rassment after any of the functional tests, should 
be allowed to engage in the athletic exercises 
above mentioned. In the present state of our 
knowledge on the subject we would especially cau- 
tion against passing individuals who show a 
marked systolic rise after exertion. 



CHAPTER VII 

BLOOD -PRESSURE IN OPHTHALMOLOGY 

Visibility of the Artery in the Eye — Importance of 
the Sphygmomanometer — Prognosis of Arteriosclerosis — 
Ophthalmoscope and Sphygmomanometer — Changes in the 
Eye in Arteriosclerosis — Diarrhoea — Anemia — Diabetes — 
Syphilis. 

The only organ of the body which is transparent 
is the eye. The blood vessels of its interior are 
thus easily inspected and we are able to follow 
definitely minute changes in the arterial system 
by watching the retinal arteries. It was long 
known that certain retinal changes accompanied 
arterial disease, but that this complex was fore- 
shadowed and in a measure due to increased 
blood-pressure has only recently been discovered. 

Perhaps in the entire domain of medicine 
there is no field in which the sphygmomanometer 
is of such paramount importance as in Ophthal- 
mology. The eye is so frequently the first sufferer 
in systemic disease, and such a continuous suf- 
ferer, that unless the systemic derangement is 
alleviated it behooves those engaged in eye work 
to acquaint themselves with the general pathology 
of the patient. 

Preventive measures are vastly more important 
and more efficient than corrective ones. In the 
majority of cases it is easier to prevent the 
destruction of tissue than it is to repair it after 
destruction has taken place. The latter may even 
be impossible. 

66 



BLOOD PRESSURE IN OPHTHALMOLOGY 67 

Every case of rising blood-pressure is poten- 
tially capable of producing the classic eye symp- 
toms of arteriosclerosis. The first symptoms may 
be refractive errors, or other slight changes before 
the patient is aware of his systemic condition. 

To a certain extent the prognosis of arterio- 
sclerosis depends on how early treatment is begun. 
The oculist, due to his peculiar position, may 
recognize these conditions in their incipiency if 
the practice of routine blood-pressure reading is 
made, and thus do much in combating the great 
group of degenerative diseases. 

We can safely say that without treatment no 
case of high blood-pressure will improve. It is 
not an acute infection which must run its course, 
but a slow insidious process which grows worse 
with time. In its incipient state, however, it is 
fairly amenable to treatment. 

It is quite true that a diagnosis of arterio- 
sclerosis as shown above can be made by the oph- 
thalmoscope, but once the disease has progressed 
to a point where we have a gross retinal lesion, a 
great deal of arterial damage has been done, and 
we are already handicapped in the race, while the 
sphygmomanometer will detect the condition 
before irreparable damage has been done. 

The ophthalmoscope and sphygmomanometer 
go hand in hand; one confirms and supplements 
the other. Routine blood-pressure determina- 
tions on every patient are of the utmost import- 
ance. In as much as the blood-pressure findings 
may influence the prescription to a marked 
degree the information should be obtained at first 



68 BLOOD PRESSURE SIMPLIFIED 

hand by the oculist himself at the first examina- 
tion of the patient. 

Some ophthalmologists complain that the added 
burden of blood-pressure determinations makes 
such a demand on their time that the work must 
be done by someone else. In view of the extreme 
simplicity of the procedure with the modern 
apparatus, the very small amount of time 
required (30 seconds) and the great importance 
of the information gained it seems almost un- 
thinkable that it should be done by anyone save 
the oculist himself. Hoover (45) speaking in 
this connection says: "I always prefer to take 
the blood pressure myself in my office than to 
have it taken by someone else, no matter what 
report may have been rendered me by the attend- 
ing physician (if one was in attendance prior to 
my seeing the case) . I have come to look upon my 
instrument as a necessary adjunct to my office 
equipment. Time in taking these readings should 
not be considered." 

To acquaint the physician with the ophthal- 
moscopic picture seen in arteriosclerosis, the fol- 
lowing is inserted. Depending on the severity and 
stage of the disease the following changes in the 
retina may be observed: 

1 — Alterations in the course and caliber of the 
retinal arteries manifesting themselves as: (a) 
undue tortuosity, which is not sufficient unless it 
is associated with other evidence of disease; (b) 
alterations in the size and breadth of the retinal 
arteries, presenting as it were, a beaded appear- 
ance. 

2 — Alterations in the reflections from, and the 



BLOOD PRESSURE IN OPHTHALMOLOGY 69 

translucency of, the walls of the retinal artery 
manifesting themselves (a) in increased distinct- 
ness of the central light streak on the retinal 
vessels and an unusual light color of the entire 
breadth of the artery; (b) loss of translucency, so 
that it is impossible to see through the artery and 
underlying vein at the point of crossing, as is 
possible in the normal state; (c) positive changes 
in the arterial walls, consisting of whitish stripes, 
indicating degeneration of the walls or infiltra- 
tion of the perivascular lymph-sheaths (perivas- 
culitis). 

3 — Alterations in the course and caliber of 
the veins, together with signs of mechanical pres- 
sure, manifesting themselves (a) in undue tortu- 
osity, which, as in the case of the arteries is not 
significant except in the presence of other dis- 
ease, (b) alternate contractions and dilatations; 
(c) an impeded venous circulation where a 
diseased artery crosses it. The last is a sign of 
the utmost importance. Ordinarily as an artery 
crosses the vein, as it may be seen by an examina- 
tion of the normal eye ground, there is no sign 
of pressure, and the translucent artery permits a 
view of the vein beneath it. If the walls of the 
artery are thickened by disease, then it presses 
upon the vein, pushes it aside or directly contracts 
its caliber, so that beyond the point of crossing 
there is an ampulliform dilatation; (d) changes 
in the whitish stripes border the vessel and are 
indications of degeneration in its walls. Often, 
associated with this, one may see varicosities. 

4 — Edema of the retina, manifesting itself as 
a grayish opacity, which may be present in the 



70 BLOOD PRESSURE SIMPLIFIED 

immediate neighborhood of the papilla, or in spots 
over the eye ground and along the course of the 
vessels, looking like a fine gray haze, or in little 
fluffy islands far out in the periphery. 

5 — Hemorrhages, manifesting themselves as 
linear extravasations along the course of the 
vessels, roundish infiltrations scattered over the 
fundus, or sometimes in a droplike form. 

The above changes might be said to be the 
result of an undiscovered or untreated systemic 
condition. It is entirely tenable that these eye 
ground phenomena could in most cases have been 
prevented by early diagnosis and treatment. That 
diagnosis rests largely on blood-pressure deter- 
mination and urinary analysis. 

Nephritis — Of 935 cases of kidney disease tab- 
ulated by Groenauw and Uhthoff (46) albumin- 
uric retinitis was present in 209, or 22.4 per cent. 
The small contracted kidney is the most frequent 
form found with retinitis. Chronic diffuse par- 
enchymatous nephritis is the next most frequent. 
Nephritis of Scarletina is last. 

Porter (47) concludes that the eye disease does 
not depend so much on the existence of the renal 
affectation as on the fact that the vessels are dis- 
eased. 

Hyper-tension is not the only systemic condi- 
tion manifesting itself in ocular changes. Many 
other conditions also may affect the eye ; as diar- 
rhoea, anemia, various stages of syphilis and other 
conditions producing low blood-pressure. 

Anemia — Anemia exercises great influence in 
eye work. Anemia is, of course, accompanied by 
hypo-tension. 



BLOOD PRESSURE IN OPHTHALMOLOGY 71 

Knies (48) states that it is only in advanced 
cases that the papilla is notably paler, but says 
that it may even be chalky white, the blood stream 
lighter, and pulsations of the vessels occasionally 
visible. He also mentions that a rather striking 
fact is the great frequency of congestion of the 
conjunctiva, also called dry catarrh, in anemia of 
all kinds. One of its main causes is probably in- 
sufficient sleep, or insomnia. 

Diabetes Mellitus— "The effects of diabetes con- 
sist objectively of pareses of the ocular muscles, 
iritis, cataract, failure of accommodation, refract- 
ive changes, retinitis, (simple hemorrhagic and 
punctate), optic neuritis, vitreous opacities, de- 
tachment of the retina (due to hemorrhage prob- 
ably) ulcer of the cornea, retinal arteriosclerosis, 
etc." 

As blood-pressure in diabetes, particularly in 
the early stages, is normal a test is largely a 
negative one differentiating between albuminuric 
retinitis and diabetes. 

Syphilis — Ophthalmology gives syphilis first 
place among the causes of disseminated chlorid- 
itis. Syphilis also plays a large part in the pro- 
duction of very many other ocular conditions, 
varying from paralysis of the third nerves to 
retro-bulbar neuritis. 



CHAPTER VIII 

BLOOD -PRESSURE IN OBSTETRICS 
AND SURGERY 

Introduction — The Therapy of Blood-Pressure Anom- 
alies in Pregnancy — Surgery — Blood-Pressure in Some 
Surgical Procedures. 

It is fortunate for the obstetrician that some 
of the most dreaded sequelae of pregnancy mani- 
fest themselves by changes in blood-pressure 
while they are yet in the incipient stage and 
respond with comparative ease to treatment. 
This makes it imperative that the blood-pressure 
readings be taken every few weeks during the 
early months of pregnancy and at shorter inter- 
vals during the later stages, as an impending 
eclampsia may be recognized by the blood-pres- 
sure reading, before the urine shows albumin. 

Blood-pressure in normal pregnancy rarely 
rises above 125 mm. In young women under 
thirty who are normal, it will be nearer 120 mm. 
After normal labor, subsidence of the uterus 
gives a slight fall. The loss of considerable blood 
will entail a greater drop in the blood-pressure. 

A tendency of the blood-pressure to rise should 
be looked upon with suspicion, even though no 
arbitrary point of hyper-tension is reached. 

According to Hirst (49) an increase of arterial 
tension, particularly in the latter months of preg- 
nancy, most infallibly points to some toxemia. 
Therefore, our chief reliance should be placed on 
the sphygmomanometer. 

72 



BLOOD PRESSURE IN OBSTETRICS AND SURGERY 73 

Hypo-tension — Hypo-tension in a patient dur- 
ing pregnancy is deserving of considerably less 
attention than hyper-tension. 

In dealing with persistently low vascular stress 
it may in many cases indicate tuberculosis com- 
plicated with pregnancy. If the patient be sup- 
ported with tonics and good food, pregnancy may 
run its course and normal labor ensue. It is to be 
remembered that in such event there may result a 
heavily handicapped child and a mother whose 
chance of future health and happiness are severely 
compromised. 

A hypo-tension discovered during pregnancy, 
dependent on myocardial lesions, or a badly com- 
pensated vascular lesion, would raise the question 
— Can this heart stand the strain of gestation and 
labor? 

THE THERAPY OF BLOOD-PRESSURE 
ANOMALIES IN PREGNANCY 

The development of hyper-tension in pregnancy 
accompanied by dizziness, headache, insomnia 
and albuminuria should lead us to active thera- 
peutic measures. Our first efforts should be 
directed toward elimination. This is secured by 
guarded catharsis, hot packs, venesection and in- 
travenous saline infusions. A great many prac- 
titioners recommend the use of veratrum viride. 
The performance of abortion, or premature labor, 
may be necessary in some cases. 

SURGERY 

While blood-pressure determinations do not 
occupy the place in surgery that they do in inter- 
nal medicine, further research shows that the rela- 



74 BLOOD PRESSURE SIMPLIFIED 

tion between blood-pressure and surgical condi- 
tions are virtually associated, and to-day every 
progressive surgeon recognizes their increasing 
importance. 

Anesthesia — Our best index of the response of 
the vital functions of the organism to the unnatu- 
ral demands made upon it during anesthesia is 
the behavior of the blood-pressure. The adminis- 
tration of general anesthesia is always a potential- 
ly fatal procedure and it is our duty to make use of 
every method which will enable us to recognize 
and forestall any condition which would tend to 
increase the hazard. In line with this policy a 
blood-pressure reading should be taken before, 
during and after every general anesthesia. 

The great circulatory catastrophy with which 
we have to deal is shock. A fall of blood-pressure, 
even if slight, during the operation should at once 
put us on our guard. The two great factors in 
its production are hemorrhage and manipulation 
of the vital organs. A fall of pressure below 100 
mm., together with a rising pulse rate, is an indi- 
cation for immediate treatment. Shock is at hand 
when the pulse pressure falls to 10 or 15 mm., or 
when the diastolic pressure falls to, or below, 
70 mm. 

McKesson (50) has developed a method which 
he finds of great value in revealing circulatory 
conditions throughout anesthesia. The cuff is 
wrapped about the arm and the end pinned with 
a safety pin so that it may be retained in position, 
without danger of slipping, throughout the period 
of the operation. 

The stethescope is conveniently held over the 



BLOOD PRESSURE IN OBSTETRICS AND SURGERY 75 

artery, below the cuff, by means of a piece of elas- 
tic webbing about one inch wide with a suitable 
buckle, so that the diaphragm portion of the 
stethescope is fairly snug against the artery. 

The tube leading to the arm piece is passed 
through a hole in the webbing and is of sufficient 
length to conveniently connect with the anesthe- 
tist. It is then possible at any time during the 
operation to make determinations by the ausculta- 
tory method of both the systolic and diastolic pres- 
sures. (See Fig. 6.) 

His technique is as follows: "The pressure in 
the cuff is pumped above the systolic pressure; 
then as the pressure is gradually released we 
listen for the first clear pulse tone which occurs 
during exhalation. This is the expiratory systolic 
pressure. As the pressure in the cuff falls grad- 
ually we hear faint pulse tones during inhalation, 
but these are disregarded until they are of equal 
intensity to the one first noted in exhalation. 
When such a tone is heard the inspiratory systolic 
reading is made. 

"The difference between the inspiratory and 
expiratory readings is the respiratory influence 
on systolic blood-pressure. Inspiratory and expir- 
tory diastolic pressures are obtained in the same 
manner. 

"Ordinarily, on inhalation, diastolic and sys- 
tolic pressures are from 5 to 20 mm. lower than 
on exhalation. When the obstruction in the air- 
way produces marked snoring the variations may 
be greater, amounting to as much as 30 mm. If 
the respirations are very rapid, however, respira- 
tory variations in blood-pressure are less marked. 



76 BLOOD PRESSURE SIMPLIFIED 

"During inhalation, blood is aspired into the 
great veins, right heart, and pulmonary arteries, 
from all parts of the body; the pulmonary capil- 
laries are straightened out and dilated, allowing an 
increased flow of blood from the right ventricle, 
but delivering a decreased quantity of blood to 
the left auricle, so that arterial pressure falls. On 
exhalation, this blood-saturated lung is com- 
pressed by the air within, and the chest wall with- 
out, thus forcing an increased quantity of blood 
into the left heart and systemic circulation and ele- 
vating the pressure for two or three heart beats ; 
at the same moment, the compression in the lungs 
has a tendency to dam back the blood from enter- 
ing the thoracic cavity, and when the obstruction 
to respiration is marked, the result is an increased 
peripheral venous congestion, especially notice- 
able in the head and neck. If the lungs are kept 
inflated under considerable pressure, the pulse 
and diastolic pressures both fall, imperfect ventil- 
ation results, venous congestion or cyanosis im- 
mediately supervene. The pulmonary obstruction 
or capillary compression may cause right heart 
dilatation. 

"From clinical observation in taking these pres- 
sures, it appears that in obese patients, in whom 
the airway at the base of the tongue is kept free 
by means of a pharyngeal tube, that the weight 
of the chest wall in some way obstructs exhala- 
tion, possibly by collapsing the smaller branches 
of the bronchial tree, and thus interfering with 
the pulmonary circulation, dams back the blood 
and produces venous congestion and cyanosis." 
McKesson (50). 



BLOOD PRESSURE IN OBSTETRICS AND SURGERY 77 

Treatment of Shock — There is considerable dis- 
cussion at the present time on the treatment of 
shock — Crile's Anoci Association theory has up- 
set many of our preconceived ideas. He depre- 
cates the use of strychnin and other so-called 
stimulants, and advises morphine. Intravenous 
injection of saline infusion is perhaps our best 
measure. 

BLOOD -PRESSURE IN SOME SURGICAL 
PROCEDURES 

Drainage of the Bladder — Balfour's (51) 
studies would seem to show that bladder drain- 
age markedly lowers blood-pressure. 

Traction of the Abdominal Viscera — Traction 
of the abdominal viscera produces a marked, and 
in many cases a dangerous fall of blood-pressure; 
also gauze dissection. 

Manipulation of the Peritoneum — Manipula- 
tion of the peritoneum, as separation of the adhe- 
sions, etc., may cause an alarming fall of blood- 
pressure. This is more liable to occur during 
work in the upper abdomen. 

Surgery of the Pelvis — There is some dispute 
on this question, although on the whole the 
vaginal route is preferable, because with the ab- 
dominal wall intact we still have the diaphragm 
to aid the venous flow. 

Intestinal Perforation — Intestinal perforation 
is usually preceded by a short rise, followed by 
an alarming descent after puncture has occurred. 

Concealed Hemorrhage — As in Ectopic Preg- 
nancy, open rupture produces a very marked fall. 



78 BLOOD PRESSURE SIMPLIFIED 

Pyelitis — Pyelitis is accompanied by a tempor- 
ary hyper-tension. 

Climacteric — The menapause is usually accom- 
panied by more or less circulatory anomalies. 
These are responsible for the subjective symp- 
toms of dizziness, "hot flashes," etc., so frequently 
referred to by women at this period of life. The 
pressure is usually left somewhat higher. 

Spinal Anesthesia — The data at hand is very 
conflicting regarding blood-pressure in spinal 
anesthesia. There are marked fluctuations begin- 
ning with the introduction of the needle and last- 
ing for some time. The drug effects do not seem 
to be consistent. The dread of the procedure 
usually brings a marked rise before operation. 



CHAPTER IX 

HEART IRREGULARITIES 

Observation by the Sphygmomanometer — Sinus 
Arrhythmia — Premature Contraction — Heart Block — Au- 
ricular Fibrillation — Pulsus Alternans. 

With the development of sphygmomanometers 
having an extremely short period, such as the 
modern diaphragm instrument, capable of giving 
us the picture of a single systole, it was imme- 
diately discovered that many irregularities of the 
heart beat were rendered easily discernible by the 
physician. 

The doctor is here again enjoined to observe 
studiously the movements of the needle while 
making his blood pressure readings. Each excur- 
sion is a direct picture of the arterial beat and 
by always noting its rhythm, rate and amount of 
movement, many things may be learned which 
would be lost to palpation alone. Several 
methods for use in special conditions will be 
described later on in the chapter. To aid in the 
recognition of some of the more common dis- 
orders of the heart beat, as shown on the dial of 
the sphygmomanometer, the following brief 
descriptions and pulse tracings are inserted. 

SINUS ARRYTHMIA 

Definition — Irregularities of the heart which 
are produced by interferences with the rythmic 
impulses at the seat of their discharge. 

Recognition — There are several forms of this 
disease, some of which are extremely rare, and 
will be omitted. The one most commonly met 
with is known as the respiratory form and will 
be described. 

79 



80 BLOOD PRESSURE SIMPLIFIED 

Respiratory Form: During inspiration and 
while the chest is expanded there is an increase 
in the rate of the heart. Expiration is accom- 
panied by a decrease in the rate. These changes 
may be so small as to escape the palpating finger 
but are easily noticed by watching the movement 
of the hand. 




Radial 

Respiratory and radial curve in a case of sinus arrhythmia. 

The pulse rate is increased with each normal inspiration 

and decreased with each expiration. — Lewis (56). 

The chief value of this observation is to assure 
ourselves that the heart is functionating normally, 
in this respect. A slowing of the heart during in- 
spiration would give us the phenomenon of pulsus 
paradoxus, indicating pericardial lesions. 

PREMATURE CONTRACTIONS 

Definition — Responses of the heart to new and 
isolated impulses formed in the musculature of 
the ventricles or auricles; contractions which oc- 
cur before the anticipated time and which con- 
sequently disturb the normal order of the heart's 
mechanism. 

Recognition — The work accomplished by pre- 
mature beats is small, because the periods of rest 
that precede them are short. They may not even 
raise the aortic valves. Accompanying the pre- 
mature beat a feeble pulsation or a prolonged 
pause is noted in the movements of the hand. By 



HEART IRREGULARITIES 



81 



closely watching the excursions of the needle the 
disturbance may be determined. 



Radial curve in a case in which a premature ventricular 
contraction replaces each fourth beat. — Lewis (56). 



Radial tracing from a case of premature auricular 

contraction. 
There is a "Bigeminy" or coupling of heart beats. — 

Lewis (56). 

HEART BLOCK 

Definition — An abnormal heart mechanism, in 
which there is a delay in, or absence of, response 
of the ventricle to auricular impulses. 

The disorders of the heart's mechanism caused 
by heart block, in its several grades, are readily 
recognized by the exact graphic methods provided 
by the polygraph and galvanometer. The efficacy 
of these instruments and the certainty of the 
analysis must be evident, for heart-block produces 
derangement of sequence in the contractions of 
auricle and ventricle, and the polygraph and gal- 
vanometer supply separate records of the systoles 
of upper and lower chambers. Therefore, a com- 
parison of the onsets of the several systoles is 
relatively simple when these recording devices are 
employed. 

The pauses occasioned by dropped beats and 
the preceding increase in the rate is very notice- 
able when using a diaphragm instrument. 

Rad+l 



Radial tracing from a case of heart-block. 

The ventricular responses fail frequently. — Lewis (56). 



82 BLOOD PRESSURE SIMPLIFIED 

AURICULAR FIBRILLATION 

Definition — A condition in which normal im- 
pulse formation in the auricle is replaced by stim- 
ulus production at multiple auricular foci. Co- 
ordinate contraction in the auricles is lost; the 
normal and regular impulses transmitted to the 
ventricle are absent, while rapid and haphazard 
impulses produced in the auricles take their place 
and produce gross irregularity of ventricular 
action. 

Recognition — The movements of the needle in 
this condition are extremely irregular, varying in 
each of their three characteristics: to wit; rate, 
rhythm and amplitude. 

Radial tracing from a case of auricular fibrillation. 
The heart's action is grossly irregular, but each ven- 
tricular beat reaches the wrist. — Lewis (56). 

The taking of blood-pressure in auricular fibril- 
lation. James and Hart (52) have elaborated 
what is termed the relative pulse deficit method. 
The pressure in the cuff, which has been raised 
above the obliteration point, is allowed to fall in 
successive steps of ten millimeters each and the 
number of waves passing through each step is 
checked against the heart rate. The lag in the 
number coming through is known as the deficit. 
These waves are counted until the point is reached 
where all come through. The average systolic 
pressure is determined from the following rule : 

Multiply the number of radial beats by the pres- 
sure under which they come through, add their 



HEART IRREGULARITIES 83 

products and divide by the number of apex beats 
per minute. 

PULSUS ALTERNANS 

Definition — A condition in which the left ven- 
tricle, while beating regularly, expels larger and 
smaller quantities of blood at alternate contrac- 
tions. 

Radial tracing from a case of Pulsus Alternans. 

Each alternate beat is strong and each alternate 

beat is weak. — Lewis (56). 

Recognition — Herrick (4) has developed a 
special technique in these cases, using the sphyg- 
momanometer. This consists in inflating the 
sleeve to a point where the waves of small ampli- 
tude are prevented from showing themselves by 
the movement of the hand, while the stronger 
waves are allowed to come through. It is thus 
seen that the pulse rate in beats per minute would 
be halved. By lowering the pressure in the cuff 
all the beats will again come through, but their 
disparity in size will be rendered more noticeable. 




PULSUS ALTERNANS 

At 210 mm. Hg. no pulse is felt at the wrist. Below 210 
and above 195 the stronger beat is felt. Below 195, 
for example, at 100, the pulse rate doubles and the 
beats are alternately strong and weak. — Herrick (4). 



CHAPTER X 

TYPES OF SPHYGMOMANOMETERS 

Introduction — Mercurial Sphygmomanometer — Dia- 
phragm Sphygmomanometer. 

To accurately measure the blood pressure, 
numerous kinds of sphygmomanometers have 
been devised. Of these only two types, the dia- 
phragm and the mercurial, have survived. 

To fulfill the exigencies met by the average 
practitioner in his daily work, it is essential that 
the sphygmomanometer possess to a high degree 
the qualities of accuracy, portability and dura- 
bility. 

Accurate determinations of blood-pressure 
make a peculiar demand upon the design and 
structural perfection of the instrument. 

First — It must accurately indicate, almost co- 
incidently with their occurrence, the rapid and 
minute changes of arterial pressure. Second — It 
must be easily portable, admitting of application 
to the arm of a patient while in a position difficult 
of access, or during movement. Third — In addi- 
tion, it must be of a construction enabling it to 
withstand the hard usage accorded it by the aver- 
age physician. 

THE MERCURIAL SPHYGMOMANOMETER 

The selection of mercury as an indicating 
medium by the early investigators was due to the 
fact that the metal is of liquid form at ordinary 

84 



TYPES OF SPHYGMOMANOMETERS 85 

temperatures, and because of its great specific 
gravity, only small quantities of the metal being 
required to balance the limits of systolic arterial 
pressure. 

Prior to mercury, water was the vehicle in com- 
mon use, but owing to the large volume required 
(water is 13 V^ times more bulky than mercury), 
a satisfactory portable instrument could not be 
constructed. 

Mercury was fairly satisfactory so long as 
blood-pressure work was limited to the determin- 
ation of the systolic pressure. Investigations dis- 
closing the value of the diastolic pressure soon 
demonstrated the inadequacy of mercury to esti- 
mate the rapid fluctuations incident to a single 
cardiac cycle. The criterion of diastolic pressure 
being the lowest point of these fluctuations, 
occurring normally 72 times per minute, the 
inertia of mercury was found too great to accu- 
rately measure them. 

This fact alone, without considering the chem- 
ical and capillary errors of the mercury column, 
is sufficient to condemn it as a vehicle for the 
purpose. 

In support of this we quote: "The variations 
of pressure in the chambers of the heart and aorta 
occur so rapidly, that, as has long been recog- 
nized, the mercury manometer is incapable of fol- 
lowing the changes accurately. This is due to the 
inertia of the mercury, i. e., the physical property 
by virtue of which it resists being set in motion 
when at rest, and strives to remain in motion 
after the acting force has ceased. This causes 
the apparatus to record an amplitude which does 



86 BLOOD PRESSURE SIMPLIFIED 

not correspond to the pressure changes actually 
involved. If a high pressure is suddenly com- 
municated to a manometer and then released, the 
mercury rises above and falls below the true level. 
The amplitude of the curves is larger than the 
true variation. If the variations recur rapidly, 
neither the highest nor the lowest pressures are 
approached and the recorded amplitude is less 
than the change which actually occurs. This is 
the case when the mercury manometer registers 
pressures within the heart and large vessels. Not 
only are the extremes of pressure incorrectly 
recorded, but the rise starts later and lags behind 
the pressure change. In other words, the inertia 
is determined by the low vibration frequency in- 
herent in the instrument. We return, therefore, 
to the physical fact that an apparatus, in order 
to record the oscillations correctly must have an 
inherent frequency that is more rapid than that of 
the swiftest pulsations to be recorded." Wig- 
gers: Circulation in Health and Disease (53). 

Brooks and Luckhardt (54) speaking of the 
mercury manometer say : 

"If the rate of the heart beat coincides with the 
period of the manometer, the oscillations are 
greatly augmented, but when the rate of the pulse 
beat is such that it clashes with the period of the 
manometer the oscillations of the manometer are 
greatly diminished, so that a given pulsatory pres- 
sure, when its rhythm is coincident with the 
period of the manometer, may cause oscillations of 
the manometer which are several times greater 
than the same pulsatory pressure at a rhythm 



TYPES OF SPHYGMOMANOMETERS 87 

which interferes or does not coincide with the 
period of the manometer." 

THE DIAPHRAGM SPHYGMOMANOMETER 

The diaphragm dial type of sphygmomanometer 
satisfies the exacting demands of blood-pressure 
work. Its design and structure render it capable 
of indicating almost coincidently with their occur- 
rence, variations of arterial pressure, making it 
the correct type of instrument for the purpose. 

The highest development of this class of instru- 
ment possesses the unique, though absolutely 
essential feature of verification; that is, should 
the instrument receive an injury damaging its 
mechanism beyond a purely negligible degree, the 
fact is at once made known by the failure of the 
hand to come to rest within the zero of the scale. 

Another advantage of the diaphragm feature is 
its portability, the pocket size of this instrument 
is conveniently carried about by the physician and 
is easily applied to the arm of his patient for 
blood-pressure determinations, irrespective of 
the position or condition of the patient, such as 
determinations during anesthesia, eclampsia, 
maniacal states, etc., and it may be left in posi- 
tion on the arm during the whole procedure of 
determining the efficiency of the circulation, no 
matter what the condition of the patient, or the 
form of exercise adopted. 

This is not only important to the physician in 
determining the circulatory condition of his 
patient during treatment, but is also invaluable in 
all health examinations, such as life insurance, 



88 BLOOD PRESSURE SIMPLIFIED 

police, firemen and in examining applicants for 
the army and navy. 

The foregoing features which attach to the dia- 
phragm type of instrument, together with its dur- 
ability, have brought it into universal use as the 
most practical instrument for physicians. 



BIBLIOGRAPHY 



1 — Hirschf elder, A. D.: Diseases of the Heart and 
Aorta— Philadelphia, 1913. 

2— Huerthle & Porter— Hirschf elder, A. D.: Dis- 
eases of the Heart and Aorta — Philadelphia, 
1913. 

3 — Erlanger, Joseph — The Mechanism of the Com- 
pression Sounds of Korotkoff. American Jour- 
nal of Physiology, March 1st, 1916. Page 82. 

4 — Herrick, J. B. — Pulsus Alternans Detected by the 
Sphygmomanometer, J. A. M. A., Feb. 27th, 
1915. 

5 — Dawson — Loc. cit. Norris, G. W.; A. B., M. D.: 
Blood Pressure. Its Clinical Applications — 
Second Edition, 1916, Philadelphia. Page 37. 

6 — Stone, W. J.: Archives of Internal Medicine, 
November, 1915. 

7 — Richter, George: Mistakes in Taking and Inter- 
preting Blood Pressure Readings. Medical 
Record, November 14th, 1914. 

8 — Henderson, Yandell: Editorial, J. A. M. A., No- 
vember 28th, 1914. 

9 — Hooker: Editorial, J. A. M. A., November 28th, 
1914. 

10 — Melvin, G. S. and Murray, J. S.: Blood Pressure 
Estimation in Children — British Medical Jour- 
nal, April 17th, 1915. 

11 — Grossman, Morris; M. D.: High Blood Pressure; 
Treatment by Means of Muscular Relaxation. 
New York Medical Journal, Sept. 25th, 1915. 

12 — Rolleston, H. D.: Blood Pressure in Typhoid 
Fever. Medical Record, April 15th, 1916. 

13— Barach, J. H. and Marks, W. L.: Effect of 
Change of Posture Without Active Muscular 
Exertion on the Arterial and Venous Pressure. 
The Archives of Internal Medicine, May, 1915. 
Page 485. 

14 — Dexter, Edwin Grant, Ph. D.: (Barometric 
Pressures) Weather Influences, New York, 
1904. 



89 



90 BLOOD PRESSURE SIMPLIFIED 

15 — Fisk, Eugene Lyman, M. D.: Increasing Mortal- 
ity in U. S. From Diseases of the Heart, Blood 
Vessels and Kidneys. (Address delivered 
before the Philadelphia Pathological Society, 
Oct. 14th, 1915), New York Medical Journal, 
January 15th, 1916. 

16— Warfield, Louis M., A. B., M. D.: Arterior- 
sclerosis, Second Edition, St. Louis, Mo. Page 
135. 

17 — Renon, L.: Continuous Morning Headaches with 
Abnormal High Blood Pressure (Paris Medi- 
cal) quoted: J. A. M. A., August 12th, 1916. 

18— Elliott, M. D.: The Treatment of High Blood 
Pressure. J. A. M. A., Sept. 18th, 1915. 

19 — Barger & Dale — Journal Physiol., 1910, xl. 38. 

20 — Miller, James Alex.: Hospital Ventilation from 
the Point of View of the Clinician. J. A. M. A., 
Nov. 7th, 1914. 

21 — Staehelin, Ueber d. Einfluss d. taglichen Luft- 
druckschwankunger auf don Blutdruck. Med. 
Klinik, 1913, ix. 862. 

22 — Bishop, L. F.: Arteriosclerosis — London, 1915. 

23 — Emmerson: Blood Pressure in Tuberculosis. 
Archives of Internal Medicine, 1911 — vii. (Bib- 
liography) . 

24— Crile (Quoted by Rolleson, H. D.) : Blood Pres- 
sure in Typhoid Fever. Medical Record, April 
15th, 1916. 

25 — Fraenkel. Quoted by Janeway, Theo. C, M. D.: 
The Clinical Study of Blood Pressure. New 
York, 1904. Page 226. 

26 — Gilbert & Castaigne. Quoted by Janeway, Theo. 
C, M. D.: The Clinical Study of Blood Pres- 
sure. New York, 1904. Page 227. 

27 — Pettey: Quoted by Norris, G. W.: Blood Pres- 
sure. Its Clinical Applications. Second Edi- 
tion. Philadelphia. Page 232. 

28 — Valenti — Experimented Untersuchunger u. d. 
chronischen Morphinismus, etc., Arch, f . exper. 
Path. u. Pharmakol, 1914. LXXV., 437. 



BIBLIOGRAPHY 91 

29 — Cannon — Cannon, Aub & Binger. A Note on the 
Effect of Nicotine, Injection on Adrenal Secre- 
tion. Jour. Phar. and Exp. Therap., 1912, iii., 
379. 

30 — Lehman — Norris, G. W.: Blood Pressure. Its 
Clinical Applications. Second Edition. Phila- 
delphia. Page 229. 

31— Lee, W. E. : The Action of Tobacco Smoke with 
Special Reference to Arterial Pressure and 
Degeneration. Quart. Jour, of Physiol. 1908. 
Page 335. 

32 — Brown. Physiological Principles in Treatment. 
London, 1914. Page 34. Brown, Landon, W.: 

33 — Lee and Scott. Action of Temperature and 
Humidity on Working Power of Muscles and 
Sugar of Blood. American Journal of Physi- 
ology. May, XL., No. 3. Page 373. 

34 — Faber. Blood Pressure with Obesity. Abs. in 
A. M. A., July 3. 

35 — Baedeker— Therap. of Gegenwart. 1910. Page 2. 

36 — daCosta. Quoted by Hirschf elder, A. D.: Dis- 
eases of the Heart and Aorta. Philadelphia, 
1913. 

37 — Robinson, Duffleld: Pilocarpine in High Blood 
Pressure. New York Medical Journal. Nov. 
7th, 1914. 

38 — Busquet. Quoted from Hart, T. Stuart: Ab- 
normal Myocardial Function. Page 136. New 
York, 1917. 

39 — Gaulthier R. (French) : Etudes physiologiques 
sur le qui Arch. Internat. d. Pharmacodynamic, 
1910. Nos. 1 and 2. 

40 — Fisher, J. W. : Diagnostic Value of the Sys- 
tolic Blood Pressure. October 7th, 1915. 

41 — Graupner: Die Mechanische Prugubf und Beur- 
theilung der Herzleistung Berlin Klinik, 1902 — 
XV. No. 174. 

42— Katzenstein : Berlin Klinik. Woch., 1907. xliv. 
No. 16. 

43 — Crampton: Blood Ptosis. New York Medical 
Journal. Nov. 8th, 1913. 

44 — Lian : Effort Tests of Cardiac Aptitude. Medical 
Record, Jan. 13th, 1917. 



92 BLOOD PRESSURE SIMPLIFIED 

45 — Hoover, F. P., M. D.: Importance of Blood Pres- 
sure to the Eye Ground Specialist. Medical 
Record. July 1st, 1916. 

46 — Goenauw & Uhthoff : The American Encyclopae- 
dia of Ophthalmology. Vol. 1, p. 208. 

47 — Porter: The American Encyclopaedia of Ophth- 
almology. Vol. 1, p. 208. 

48 — Knies. The Eye in General Disease. 

49 — Hirst, John C: Blood Pressure in Pregnancy. 
Penn. Medical Journal. Page 615. May 15th, 
1915. 

50 — McKesson, E. I.: Blood Pressure in General 
Anesthesia. American Journal of Surgery. 
January, 1916. 

51— Balfour, D. C.: Mayo Clinics, 1913, p. 73. 

52 — James & Hart; James, W. B. and Hart, T. S.: 
Auricular Fibrillation. Clinical Observation 
on Pulse Deficit, Digitalis and Blood Pressure. 
American Jour. Med. Sci., 1914. CXLLII., 63. 

53 — Wiggers, Carl J.: Circulation in Health and Dis- 
ease. Philadelphia, 1915. 

54 — Brooks and Luckhardt: The Chief, Phys. Mech- 
anism Concerned in Clinical Methods of 
Measuring Blood Pressure. American Journal 
of Physiology. March 1st, 1916. Page 49. 

55 — Oliver, George: Studies of Blood Pressure, 
Physiological and Clinical. Third Edition. 
London, England. 

56 — Lewis, Thomas; Clinical Disorders of the Heart 
Beat. London, 1912. 



INDEX 



93 



Aconite 










50 


Acromegaly 










40 


Addison's Disease 










41 


Alcohol 










23 


Alkali 










50 


Alternation of the Pulse 










12 


Altitude 










36 


Ammonium Carbonate 










45 


Anemia 










42-70 


Anesthesia, Blood Pressure i 


n 








74 


Angina Pectoris . 










28 


Apoplexy 










30 


Application of the Sleeve 










7-58 


Arteriosclerosis 












Blood Pressure in 










24 


Definition . 










22 


Diagnosis . 










24 


Etiology 










22 


Heredity 










22 


Hyper-tension 










21 


Occupation 










23 


Renal Disease 










24 


Prognosis . 










25 


Symptoms . 










25 


Syphilis 










23 


Asphyxia .... 










29 


Athletics .... 










64 


Atmospheric Influences 










19-32 


Auricular Fibrillation . 








12-82 


Auscultatory Method of Taking Blood Pressure 


6-11 


Auto Intoxication ..... 


28 


B 

Baedeker ........ 48 


Balfour .... 








77 


Balneology (See Hydrotherapy) 








44 


Baring the Arm, Advisability of . 








7 


Barger and Dale . 








28 


Barnard and Hill 








2 


Barometric Pressure 








19 


Baths (See Hyprotherapy) 








44-4J 


>-47-48 



94 



BLOOD PRESSURE SIMPLIFIED 



Belladona ..... 






50 


Bishop . . 






33 


Bladder Drainage . 






77 


Blood Pressure ..... 








In Angina Pectoris 






28 


In Aortic Regurgitation 






29 


In Arteriosclerosis 






24-37 


In Athletics 






64 


In Auricular Fibrillation 






12-82 


In Auto-Intoxication . 






28 


In Bladder Drainage . 






77 


In Diabetes .... 






41-71 


In Epilepsy 






37 


In Infants and Children 






17 


In Measles . 






35 


In Meningitis 






30 


In Myzedema . 






42 


In Nephritis 






26-70 


In Perforation of the Intestines . 






77 


In Plumbism .... 






39 


In Pneumonia 






34 


In Pregnancy 






73 


In Puberty 






18 


In Pyelitis 






78 


In Renal Disease 






24 


In Rheumatism .... 






35 


In Scarlet Fever 






35 


In Shock .... 






74-77 


In Spinal Anesthesia . 






78 


In Status Lymphaticus 






41 


In Syphilis 




2 f i 


5-36-71 


In Tuberculosis .... 






33 


In Tumor (Brain) 






30 


In Typhoid Fever 






34 


In Uremia 






28 


In Visceral Sclerosis . 






25 


Effect of: 


Emotions . . . . . 21 


High-frequency Currents 






48 


Hunger 






32 


Massage . 






48 


Menstruation 






21 


Micturition 






32 


Morphinism 






39 


Posture 






18 


Rest .... 






44 


Sexual Continence 






23 


Strychnin 






46 


Thyroid Extracts 






50 



INDEX 



95 



Time of Day . 

Tobacco .... 

Tonics .... 

Warm Baths 
Influence of: 

Barometric Pressure . 

D'arsonvalization 

Defecation 

Atmosphere 

Exercise .... 

Peritoneum Manipulation . 
Auscultatory Method of Estimating 
Normal ..... 
Peripheral Factors of 
Relative Values of 
Systolic ..... 
When to Take .... 
Busquet ...... 



Cachexia 

Caffein 

Camphor 

Cannon 

Carbonated Brine Baths 

Cardiac Aptitude 

Climacteric 

Climate 

Concealed Hemorrhage 

Crampton's Test . 

Crile .... 

Cushing 

Cyanosis 



daCosta ....... 

D'arsonvalization ..... 

Dawson Method of Estimating Mean Pressure 
Defecation ....... 

Dementia Praecox ..... 

Dexter ....... 

Diabetes ....... 

Diaphragm Sphygmomanometer . 

Diarrhea ....... 



96 



BLOOD PRESSURE SIMPLIFIED 



Diastolic Pressure 












5 


Definition . 










5 


Auscultatory Method . 










11 


Diet .... 










51 


Dietetics . . 










46 


Digitalis . 










51 


Diphtheria . . 










35 


Disease, Addison's 










41 


Drug Intoxications 










23 


Dunin .... 










41 


E 


Edema of the Retina ...... 69 


Elliott 












27 


Emmerson . 












34 


Emotions 












21 


End Pressure 












1 


Epilepsy 












37 


Epinephrin . 












45 


Erlanger 












3-9 


Estimation of Diastolic Pressure 








11 


Estimation of Palpatory Method 








12 


Estimation of Systolic Pressure 








12 


Exercise .... 








. 32-44 


Exogenous Intoxications 








39 


F 
Faber . . 42 


Fisher's Tables 54-55 


Fisk 23-37 


Fraenkel 35 


Functional Tests for Cardiac Efficiency . . 60 


G 


Gaultier, R 51 


Gibson's Rule 












35 


Gilbert & Castaigne 












35 


Glandular Extracts 












36 


Gout . 












41 


Graupner's Test . 












61 


Groenauw & Uhthoff 












70 


Grossman 












, 18-48 



INDEX 



97 



H 

Heart Block 

Diagnosis . 
Heart Load Ratio 
Hemorrhage Cerebral 
Henderson, Yandell 
Herrick's Method — Pulsus Alternans 
High-frequency Currents 
Hirschfelder 
Hirst . 
Hooker 
Hoover 
Hot Baths . 
Huerthle & Porter 
Humidity 
Hunger 
Hydrotherapy 
Hypo-tension 

Definition 
Hypo-tension 

Definition 

Dietetics 

Of effort 

Headache 

Therapeutics 

Treatment 



l_30_3i_ 



Increased Intracranial Tension 

Infants and Children, Blood Pressure in 

Insurance Examinations 

Intestinal Perforation . 

Intraventricular Pressure 

Iodids 

Iron, Quinine, Strychnin 



James & Hart 

Janeway 

Josue 



82 

3-35 

25 



98 



BLOOD PRESSURE SIMPLIFIED 
K 



Katzenstein's Method 

Knies . 

Korotkoff 



62 

71 

3-9-11 



Lateral Pressure 

Lee 

Lee & Scott 

Lehman 

Lian . 



1 
40 
41 
40 
63 



M 



Marey 



Masing 

Maximal Pressure 

McKesson 

Mean Pressure 

Measles 

Mechanism of Circulation 

Melvin and Murray 

Meningitis . 

Menstruation 

Mercurial Sphygmomanometer 

Method of Determining Blood Pressure 

Method of Taking Blood Pressure in 

Fibrillation 
Micturition . 
Miller, J. A. 
Minimal Blood Pressure, First Determination 
Minimal Pressure 
Mistletoe 
Morphinism 
Mosso 
Movements of the Hand, Information to 

By . 
Myxedema . 



Auricular 



of 



Be Gained 



2 

48 

3 

4 

74-76 

13 

35 

3 

17 

30 

21 

84 

6 

82 

32 

32 

2 

4 

51 

39 

3 

11 
42 



INDEX 



99 



N 



Nauheim Baths . 




. 




47 


Nephritis 


. 


26-70 


Neuresthenia 


. 


42 


Normal Blood Pressure 


>..... 


17 


Obesity 





41 


Oliver 


. 


2 


Ophthalmoscope . 


. 


24-67 


Ophthalmology 


. 


66 


Anemia 


.... 


70 


Arteriosclerosis 


.... 


25-67 


Diabetes 


. . * . 


71 


Diarrhoea . 




70 


Nephritis . 


. 


70 


Syphilis 


. 


70 


Oscillatory Method 




6-13 


Oscillatory Method of Determining Blood Pressure 


6-13 


Over Eating 




23 


Oxygen Baths 


. 


48 


Palpatory Method 


P 


6-12 


Perforation, Intestinal 


. 




77 


Peripheral Factors in Blood Pressure . 




15 


Peritoneum, Manipulation of 




77 


Perivasculitis 


. 




69 


Pettey 


. 




39 


Physical Therapeutics, 


Hyper-tension . 




47 


Physical Therapeutics, 


Hypo-tension 




44 


Physiological Causes oJ 


Transitory Rises in 


Blooc 


1 


Pressure 


. 




20 


Pilocarpine . 




. 




50 


Pituitary Extract 




. 




46 


Plumbism 




. 




39 


Pneumonia . 




. 




34 


Poiseuille's Law . 




. . 




15 


Porter 




. . 




70 


Posture 




, . 




18-58 


Potassium Iodid . 




. . 




45 



100 



BLOOD PRESSURE SIMPLIFIED 



Pregnancy . 
Premature Contractions 
Pressure Lateral 

Maximal 

Mean 

Minimal 

Venous 

Prognosis of Arteriosclerosis 
Psychic Treatment 
Puberty 

Pulse Amplitude . 
Pulse Pressure 
Pulsus Alternans 
Pyelitis 



Quinine 

Radium 

Renal Disease 

Renon, L. 

Respiratory Gymnastics 

Rest . 

Rheumatism 

Richter 

Riva-Rocci . 

Robinson 

Rolleston 



Q 



R 



Scarlet Fever 

Sexual Continence 

Shock . 

Sinus Arrhythmia 

Sounds, Causes of 

Spinal Anesthesia 

Splanchnic Factors 

Splanchnic Vessels 

Spray Baths 

Staehelin 

Status Lymphaticus 

Stethoscope 



INDEX 



101 



Stone — Heart Load Ratio 


. 14-21 


Strychnin ...... 


45 


Surgery, Blood Pressure in . 


73 


Syphilis ...... 


23-36-71 


Systolic Pressure .... 


5 


Estimation Auscultatory Method . 


11 



Technique of Life Insurance Examinations 

Therapeutics of Hypo-tension 

Three Factors in Blood Pressure 

Thyroid Extract . 

Time of Day for Taking Blood Pressure 

Tobacco ..... 

Tonic 

Transitory Causes of Hypo-tension 
Transitory Rises (Hyper-tension) 
Traube-Hering Waves . 
Treatment of Hypo-tension . 
Tuberculosis 
Tumor, Brain 

Types of Sphygmomanometer 
Typhoid Fever 

U 
Ultraviolet Ray . 
Uremia .... 

V 
Valenti .... 

Value, Relative of Blood Pressures 
Valvular Lesions . 
Venous Pressure . 
Vessels, Sphlanchnic 
Vierodt .... 

Visceral Sclerosis 
Viscosity .... 
V. Basch .... 



Warfield 
Warm Baths 
When to Take 
Wiggers 



W 



Blood Presure 



14-22-23-24-25-26-27 

47 
14 
86 



